Root Operation Dilemma: Control vs. Destruction

A 67 year old male who had been experiencing frequent melena presents to the hospital for work up and treatment. An esophagogastoduodenoscopy (EGD) was performed with the finding of a medium sized angioectasia (AVM) seen in the mid jejunum which was thought to be the source of the bleeding. As a result, the following procedure was performed:

A single medium angioectasia (AVM) was seen in the mid jejunum. An Argon-Plasma Coagulator (APC) was applied for hemostasis successfully.

When one sees the term “coagulator”, the first thought is destruction of the lesion. Per Coding Clinic, APC is a “new method of electrocoagulation that allows for noncontact application of electrical energy to achieve tissue destruction or hemostasis. APC uses high-frequency electrical current delivered via ionized argon gas”.[1]  In Coding Clinic ICD-9-CM, the coder was directed to destruction category, 45.3x for APC of duodenum and jejunum bleeding arteriovenous malformations.[2]

When referencing the root operation definition for “destruction”, the coder finds the description to be consistent with the use of an Argon-Plasma Coagulator. The definition states physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent. However, in order to select the correct root operation, the coder must determine the objective of the procedure.

Per the ICD-10-PCS Manual, the root operation is based on the objective of the procedure. In the procedure above, the main objective was to stop the bleeding from the AVM in the jejunum; note the “for hemostasis successfully” documentation. In FY 2017, the definition for root operation “control” was changed from stopping, or attempting to stop, postprocedural bleeding to stopping, or attempting to stop, postprocedural or other acute bleeding.[3] The definition was changed to address situations when no other root operation was applicable when bleeding was being controlled but was not a postprocedural bleed.

ICD-10-PCS Guideline B3.7 states “If an attempt to stop postprocedural or other acute bleeding is initially unsuccessful and to stop the bleeding requires performing any of the definitive root operations  Bypass, Detachment, Excision, Extraction, Reposition, Replacement or Resection then that root operation is coded instead of Control”. Destruction is not listed as one of the other definitive root operations in the guideline indicating “Control” is the correct root operation for APC procedures in treatment of bleeding sites.

The distinction between “control” and “destruction” can also have implications for correct DRG assignment. See the table below for the difference in DRG assignment for the procedure under discussion when coding “control” vs. “destruction” as the root operation. One is a Surgical DRG and the other is Medical DRG.


ICD-10-CM Code ICD-10-PCS Code DRG
K55.21      Angiodysplasia of colon with hemorrhage


0D5A8ZZ       Destruction of Jejunum, Via Natural or Artificial Opening Endoscopic DRG 346    Minor Small & Large Bowel Procedures w/o CC/MCC
K55.21     Angiodysplasia of colon with hemorrhage


0W3P8ZZ       Control Bleeding in Gastrointestinal Tract, Via Natural or Artificial Opening Endoscopic DRG 379     G.I. Hemorrhage w/o CC/MCC


[1] Coding Clinic, 2nd Quarter 2004, p. 12-13

[2] Coding Clinic, 2nd Quarter 2011, p. 7

[3] Coding Clinic, 4th Quarter 2016 p. 99-101

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