January 16, 2014 | | Comments 0
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ICD-10-PCS root operation: Creation

Odds are, most coders will never use ICD-10-PCS table 0W4. Why? Because root operation 4 is creation (making a new genital structure that does not physically take the place of a body part). Unless the physician is performing a sex change operation, you won’t report creation.

TipsCreation is not used to report creation of an anastomosis or a bypass or a pouch for a pacemaker. It’s only used for sex change operations.

If you do code for these procedures, you have a very small table. You have only two choices for a fourth character:

  • M, perineum, male
  • N, perineum, female

You pick the fourth character based on the current gender of the patient. The qualifier (seventh character) identifies the body part being created (0 for vagina, 1 for penis).

The approach is always open. The only other information you need is the device, and you have four choices:

  • 7, autologous tissue substitute
  • J, synthetic substitute
  • K, nonautologous tissue substitute
  • Z, no device

If the physician harvests tissue from the patient to create the new penis or vagina, report a code for the harvesting procedure in addition to the creation operation. The seventh character for the creation in this case would be 7.

If the tissue comes from a donor tissue bank, use the seventh character K. You would only report the creation procedure.


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Filed Under: Coding


Michelle A. Leppert About the Author: Michelle A. Leppert, CPC, is a senior managing editor for JustCoding.com. JustCoding provides coders, coding supervisors, and health information management (HIM) directors with educational resources to test their coding knowledge, employ correct coding guidelines, and stay abreast of CMS transmittals.

In addition, she writes and edits the HCPro publication, Briefings on Coding Compliance Strategies. Email her at mleppert@hcpro.com.

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