ICD–10–PCS Application

The International Classification of Diseases, 10th Revision, Procedure Coding System (ICD–10–PCS) (CMS-10774)

Documents and Forms

Document Name Document Type
Form CMS-10774 ICD–10–PCS Application Form and Instruction
CMS-10774 International Classification of Diseases, 10th Revision, ICD-10 Request Preview.pdf Form and Instruction
CMS-10774 International Classification of Diseases, 10th Revision, ICD-10 Request Preview.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	ICD–10–PCS Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 162.1002

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10774	International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) Request Preview	ICD-10 Request Preview.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 80	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	80	80
Annual IC Time Burden (Hours)	800	800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.