What are the coding guidelines for the root operation inspection?

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Expert Solution

According to the ICD-10-PCS coding structure, Root operation represents the character 3. They are totally 31 root operations. The default root operations are most commonly Inspection and Repair. Inspection is represented by the character 'J'. Inspection represents the examination of the body part either visually or manually and with the use of or without any optical instrumentation.

ICD-10-PCS Coding Guidelines For Inspection:

B3.11a The coding is done based on the inspection of the body part. The objective is not coded separately. For EX: Irrigation of bronchus is done through the fiberoptic Bronchoscopy. The coding is done for irrigation procedure.
B3.11b It denotes the visualization of multiple tubular body parts. In that case the Farthest part (distal part must be coded). For EX: Inspection of cystourethroscopy, the distal part of ureter should be coded.
In the Case of inspection of multiple non-tubular body parts, the coding should be done based on the entire focused body parts. For EX: The inspection of body content through Laporatomy can be coded as peritoneal cavity body part.
B3.11c If one more procedure is performed along with the inspection procedure using different approach then the inspection should be coded separately.

For EX: when the inspection and excision of the duodenum are done at the same time, then the inspection of duodenum should be coded separately.

Note:

B3.3 In case of any discontinued procedure, then the root operation of inspection should be coded. For EX: if the procedure of thoracoscopic excision is discontinued, then it should be coded as inspection rather than excision.

Nightingale answered 1 year ago

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