Dilation: one of  icd 10 pcs root operations

Four-root operations are used to alter the diameter or route of tubular body part, Restriction, occlusion, dilation and bypass. Tubular body parts are the hollow body parts that provide a route of passage of solids, liquids or gases. This includes cardiovascular system, gastrointestinal, genitourinary, biliary and respiratory tracts. Dilation is the key root operation among all of these. The main objective of root operation dilation is just to expand or enlarge the diameter of the orifice or lumen of a tubular body part. While the icd 10 pcs root operations “Restriction” and “Occlusion” differs slightly with Dilation.  Let us learn more about root operation dilation with the help of below example.

Coding tips for Dilation: one of the icd 10 pcs root operations

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Sample Report for icd 10 pcs root operations: Dilation

PROCEDURE: Esophagogastroduodenoscopy with esophageal dilation.
INDICATIONS:  Anorexia history of esophageal stricture epigastric discomfort.
INSTRUMENTS: Olympus video upper endoscope.
MEDICATIONS: Versed 3 mg IV and Demerol 25 mg IV.
PHYSICAL EXAMINATION: GENERAL: The patient was in no distress. VITAL SIGNS: Stable.
CHEST: Clear  CARDIAC: Regular rate and rhythm. ABDOMEN: [Nondistended, nontender]. NEUROLOGIC: The patient was alert and oriented.
DESCRIPTION OF PROCEDURE:  Ms. Nancy was placed in a left lateral position and IV sedation was given in small incremental doses for the patient’s comfort for moderate sedation. The throat was anesthetized with Cetacaine spray.The endoscope was advanced without difficulty into the duodenum.
ESOPHAGUS: Esophagus had gastroesophageal junction located at 37 cm.  The GE junction was distended to 1.4 cm.  The distal esophagus was slightly inflamed.  The distal esophagus was slightly torturous.  The endoscope passed through the stricture without resistance.  ].
STOMACH: [Stomach had normal mucosa.  The fundus could not be well visualize.  There was a significant amount of food debris present within the stomach.  This was mainly liquid is semi solid.  A large hiatal hernia was present..
DUODENUM: The duodenum was normal.
The endoscope was removed and Ms. Nancy was placed in a sitting position.  A 50, 52 and 54 French Maloney dilator was passed in the stomach with minimal resistance.  There is no blood on any the dilators on withdrawal.
The patient tolerated the procedure well.
1.  Distal esophageal stricture  1.4 cm dilated to 54 French
2.  Mild esophagitis
3. Large hiatal hernia
4. Large amount of food debris in the stomach

ICD 10 PCS code

0D758ZZ – Dilation of Esophagus
Section- Medical and surgical (0)
Body system- Gastrointestinal system (D)
Operation- Dilation (expanding an orifice or the lumen of a tubular body part) (7)
Body part- Esophagus (5)
Approach- Via Natural or Artificial Opening Endoscopic(8)
Device- No device (Z)
Qualifier- No Qualifier (Z)

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                   Short ICD 10 coding guidelines for Medical coders

Now, you can easily understand with ICD 10 PCS code, how the root operation “dilation” is used in operative report by Inpatient coders. For coding correct ICD 10 PCS, code one should select correct section, body system, operation, body part, approach, device and qualifier. It takes little practice to understand each section of these codes. Once you practice few sample charts you can easily code ICD 10 PCS codes.