Alteration is one of three root operations termed as having
“other objectives.” The others are Fusion and Creation. It is
identified by using “0” for the third character in a seven character
ICD-10 PCS code and denotes the type of procedure performed.
The root operation Alteration is defined as modifying the
anatomical structure of a body part without affecting the function
of the body part (ICD-10 PCS Training Manual, 2013). The
procedure can be performed on the entire body part or on a
portion of the body part. The primary purpose of an Alteration
procedure is to improve the cosmetic appearance of a body part.
It is found in the Medical and Surgical Section and is used in the
Body Systems: Eye, Ear/Nose/Sinus, Mouth/Throat, Skin/Breast,
Subcutaneous Tissue/Fascia, Anatomical Regions, General, and
Anatomical Regions, Upper & Lower Extremities. Some of the
most common and well-known cosmetic procedures are breast
augmentations, facelifts, and liposuctions. The confusion comes
into play when the procedure is not easily identified as either
“cosmetically” or “medically” necessary.
One of the guidelines for Root Operations state, “In order to
determine the appropriate root operation, the full definition of
the root operation, as contained in the PCS Tables, must be
applied (ICD-10 PCS Training Manual, 2013).” This causes a
dilemma in choosing the correct root operation in some cases
when it becomes necessary to determine if the procedure is being
performed for medical or cosmetic reasons. Sometimes the
distinction is difficult to ascertain. The coder must rely upon the
diagnostic documentation of the physician and/or surgeon. In
order to use the root operation Alteration the documentation must
substantiate its use by indicating the procedure is being carried
out for cosmetic reasons. Otherwise, one of the other medical
root operations, such as, Extraction, Reposition, Resection,
Repair, etc. becomes appropriate and must be used instead (ICD-
10 PCS Training Manual, 2013).
ALTERATION—ROOT OPERATION “0”
WHAT TO EXPECT
1 Alteration—Root Operation
2 Coding Scenario
3 Spaced Repetition Sign-Up
4 Requests for Coding Topics
“The procedure is not
easily identified as
either cosmetically or
Volume 1 Issue 4
By Cynthia Brown, MBA, RHIT, CCS
CCHIS, P.O. Box 3019, Decatur, GA 30031 404-992-8984
CODING YESTERDAY’S NOMENCLATURE TODAY®
When to Use the Root Operation “Alteration”
In ICD-10 PCS Coding
CODING NEWSLETTER FOR HEALTHCARE
Page 2 Coding Yesterday’s Nomenclature Today
The patient is a 61-year-old female who presents with a
complaint of constricted vision in both eyes secondary to drooping
eyelids restricting reading and driving. On previous office exam,
the patient was noted to have a severe ptosis with absence of lid
crease and a poor levator function on both sides in addition to
excess and redundant eyelid skin with edema. After discussing
these findings with the patient and obtaining visual fields, taped
and untaped, and confirming that a significant functional superior
field defect was present in both eyes and after obtaining clinical
photographs, the patient agreed to have bilateral blepharoptosis
repair by external levator resection and bilateral blepharoplasty.
The patient’s pre-operative diagnosis is bilateral upper eyelid
lateral levator aponeurotic ptosis due to senescence and bilateral
upper eyelid functional dermatochalasis.
Without going into great detail describing the actual
procedure let’s take a look at the selection of the ICD-10 PCS root
operation for blepharoplasty. The coder may be tempted to use
the root operation Alteration in this coding scenario, because the
procedure “modifies the anatomical structure of a body part
without affecting the function of the body part.” It does not,
however, meet the second criteria for using the root operation;
which is to “solely change the appearance of a body part for
cosmetic reasons.” The PRINCIPAL purpose in this scenario is not
to solely improve the appearance of the patient. The
blepharoplasty and brow ptosis is considered MEDICALLY necessary
because it is performed for medical reconstructive purposes
validated by the documented visual impairment. Notice also, that
the procedure is being performed on the upper eyelid.
Blepharoplasty on the lower lids is considered COSMETIC and would
use the root operation Alteration. Therefore, the correct root
operation for the above-mentioned scenario would be repair
“restoring to the extent possible, a body part to its normal
anatomic structure and function.
It is imperative that the coder assigns the appropriate
code(s) based upon the diagnostic documentation provided in the
health record. If the documentation is unclear or incomplete it is
the responsibility of the coder to get clarification. Remember
some surgical procedures can be performed for either MEDICAL or
COSMETIC reasons and the coder should not make assumptions as to
which one applies. Do not hesitate to query the physician.
Blepharoptosis “drooping eyelids”
“The patient has
constricted vision in
both eyes secondary to
restricting reading and
Coding Yesterday’s Nomenclature Today
The presumption behind spaced repetition is simple. When we first
learn a fact, the memory of it is fresh, but subject to change or it
simply disappears. Each time we encounter that fact again,
however, the memory becomes a more established part of our
knowledge, especially if the encounters are spread out over time.
In other words, exposing your mind to that same fact multiple
times over weeks or months fixes it firmly in your brain. If you or
your staff would like to receive facts pertaining to the ICD-10
CM/PCS nomenclature over the next months to assist them in
mastering the code set—visit the CCHIS website and sign up.
Participation is free. Leave your e-mail address and name.
Spaced-out learning sessions will begin 05/01/2014 once a week.
HOW IS YOUR MEMORY?
Coding Health Information Services ®
AHIMA approved ICD-10 CM/PCS
“KEEPING THE MOMENTUM GOING”
ALL THINGS CODING®
complete coding is a
must in today’s
Page 4 Coding Yesterday’s Nomenclature Today
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CODING YESTERDAY’S NOMENCLATURE TODAY®