Coding Clinic for CDI: Defining root operations

by Sharme Brodie, RN, CCDS

Many of the questions and answers supplied in AHA Coding Clinic for ICD-10-CM/PCS, Second Quarter
2015, surrounded the use of the correct root operation. Per ICD-10-PCS Official Guideline for Coding and
Reporting, “[i]t is the coder’s responsibility to determine what the documentation in the medical record
documentation equates to in the PCS definitions.” It could very well be the CDI’s responsibility, however,
to make sure the medical record contains all the documentation necessary for the coding team to assign the correct “root operation.”