When should a coder report multiple procedures performed during a single operative session in ICD-10-PCS? Look to the official guidelines for information.
According to the guidelines, coders should not separately code components of a procedure specified in the root operation definition and explanation. They should also not separately code procedural steps necessary to reach the operative site and close the operative site.
For example, the resection of a joint as part of a joint replacement procedure is included in the root operation definition of replacement and is not coded separately. A laparotomy performed to reach the site of an open liver biopsy is not coded separately.
However, in certain circumstances, coders should report codes for both procedures. According to the guidelines, during the same operative episode, multiple procedures are coded if:
- The same root operation is performed on different body parts as defined by distinct values of the body part character. For example, separately code a diagnostic excision of the liver and pancreas.
- The same root operation is repeated at different body sites that are included in the same body part value. For example, an excision of the sartorius muscle and excision of the gracilis muscle are both included in the upper leg muscle body part value, and coders should report multiple procedures.
- Multiple root operations with distinct objectives are performed on the same body part. For example, coders should code destruction of sigmoid lesion and bypass of sigmoid colon separately.
- The intended root operation is attempted using one approach, but is converted to a different approach. For example, the physician coverts a laparoscopic cholecystectomy to an open cholecystectomy. In this case, code a percutaneous endoscopic inspection and open resection.
Coders must make sure the documentation fully supports reporting both procedures. If the documentation is incomplete or you are unclear about what the physician did, query the physician for more information.