Cracking the Code

Coding Procedures for Inpatient Accounts

When coding inpatient procedures, it is very possible that a coder will have to report multiple procedures for one encounter. It is important for coders to remember the directive about how to properly capture multiple procedures. Per the ICD-10-PCS Official Guidelines for Coding and Reporting FY 2021 Section B3.2, multiple procedures are reported if:

  • The same root operation is performed on different body parts as defined by distinct values of the body part character (i.e. excision of
  • The same root operation is repeated in multiple body parts, and those body parts are separate and distinct body parts classified as a single ICD-10-PCS body part value
  • Multiple root operations with distinct objectives are performed on the same body part
  • The intended root operation is attempted using one approach but is converted to a different approach
Reference: References: ICD-10-PCS Official Guidelines for Coding and Reporting FY 2021 Section B3.2
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