MEMORANDUM
To: New Coders
From: Coding Supervisor
Date: March 7, 2018
Subject: Root Operation/Medical and Surgical Guidelines
Good Morning New Coders,
With all the new coders I thought it would be best to give some initial insight on the ICD-10-PCS
Coding Guidelines. I would like to discuss two of the Root Operation guidelines found under the Medical
and Surgical guidelines section in the front of the code book. I would like to start with the common
principle “Coding with Integrity”. The demand for trustworthy data has never been more apparent than
m
it is today, and the coding process plays a critical role in meeting the need for complete, accurate, and
er as
reliable healthcare data. Therefore reading, understanding and using the guidelines in your coding book
co
is very important.
eH w
o.
I would like to outline two of the root operations to help you understand how these guideline work
rs e
and what they mean and how to code using the guidelines. Here are some examples of procedures, their
ou urc
definitions, instructions, and the guidelines to help you with ICD-10-PCS codes.
Starting with the root operation guidelines for biopsy procedures under the medical and surgical section:
o
Biopsy procedures
aC s
B3.4a
vi y re
Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier
Diagnostic.
Examples: Fine needle aspiration biopsy of fluid in the lung is coded to the root operation Drainage with
ed d
the qualifier Diagnostic.
ar stu
Biopsy of bone marrow is coded to the root operation Extraction with the qualifier Diagnostic.
is
Lymph node sampling for biopsy is coded to the root operation Excision with the qualifier Diagnostic.
Th
What this means is, a Fine-needle aspiration biopsy is reported with the root operative term “Drainage”
(taking or letting out fluids and/or gases from a body part). This is actually more specific and accurate, as
the physician uses a thin needle to draw out-or-drain-some fluid or gas to be used for testing.
sh
For example, an amniocentesis would be reported with ICD-10-PCS code 10903ZU (Drainage of amniotic
fluid, diagnostic from products of conception, percutaneous approach). Each of the characters making up
the code would be:
1 Obstetrics
0 Pregnancy
This study source was downloaded by 100000805705997 from CourseHero.com on 11-13-2021 01:50:56 GMT -06:00
https://www.coursehero.com/file/30935543/him-1103-Module-05-Course-Project-ICD-10-PCS-Code-Building-Guidelines-030718docx/
To: New Coders
From: Coding Supervisor
Date: March 7, 2018
Subject: Root Operation/Medical and Surgical Guidelines
Good Morning New Coders,
With all the new coders I thought it would be best to give some initial insight on the ICD-10-PCS
Coding Guidelines. I would like to discuss two of the Root Operation guidelines found under the Medical
and Surgical guidelines section in the front of the code book. I would like to start with the common
principle “Coding with Integrity”. The demand for trustworthy data has never been more apparent than
m
it is today, and the coding process plays a critical role in meeting the need for complete, accurate, and
er as
reliable healthcare data. Therefore reading, understanding and using the guidelines in your coding book
co
is very important.
eH w
o.
I would like to outline two of the root operations to help you understand how these guideline work
rs e
and what they mean and how to code using the guidelines. Here are some examples of procedures, their
ou urc
definitions, instructions, and the guidelines to help you with ICD-10-PCS codes.
Starting with the root operation guidelines for biopsy procedures under the medical and surgical section:
o
Biopsy procedures
aC s
B3.4a
vi y re
Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier
Diagnostic.
Examples: Fine needle aspiration biopsy of fluid in the lung is coded to the root operation Drainage with
ed d
the qualifier Diagnostic.
ar stu
Biopsy of bone marrow is coded to the root operation Extraction with the qualifier Diagnostic.
is
Lymph node sampling for biopsy is coded to the root operation Excision with the qualifier Diagnostic.
Th
What this means is, a Fine-needle aspiration biopsy is reported with the root operative term “Drainage”
(taking or letting out fluids and/or gases from a body part). This is actually more specific and accurate, as
the physician uses a thin needle to draw out-or-drain-some fluid or gas to be used for testing.
sh
For example, an amniocentesis would be reported with ICD-10-PCS code 10903ZU (Drainage of amniotic
fluid, diagnostic from products of conception, percutaneous approach). Each of the characters making up
the code would be:
1 Obstetrics
0 Pregnancy
This study source was downloaded by 100000805705997 from CourseHero.com on 11-13-2021 01:50:56 GMT -06:00
https://www.coursehero.com/file/30935543/him-1103-Module-05-Course-Project-ICD-10-PCS-Code-Building-Guidelines-030718docx/
