Health Information Management

Robotic-assisted procedures: Transitioning from ICD-9-CM to ICD-10-PCS

JustCoding News: Inpatient, October 24, 2012

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by Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC

Now that CMS has delayed the ICD-10-CM/PCS compliance date to October 1, 2014, the challenge for coders will be to learn—as well as maintain—their proficiency in the new system. ICD-10-PCS may be particularly difficult. Coders must not only learn the ICD-10-PCS system and its guidelines, but they must also possess a clear understanding of devices, anatomy, and physiology.
 
For the purposes of this article, I will discuss coding robotic-assisted procedures in ICD-10-PCS and provide some of the ways in which coders can prepare now to overcome any potential barriers.
 
ICD-9 procedure coding
When using robotic assistance, laparoscopic surgeons gain technical skill as well as these advantages:
 
  • Enhanced vision of the operative field from the scope
  • Improved manual dexterity for fine motor procedures (e.g., lysis of adhesions within the abdominal cavity)
  • Increased ability for surgical precision of incision, excision, reattachment, and opening/closing of the surgical operative field
Coders currently report one of the following ICD-9-CM procedure codes to denote robotic-assisted procedures:
  • 17.41, open robotic-assisted procedure
  • 17.42, laparoscopic robotic-assisted procedure
  • 17.43, percutaneous robotic-assisted procedure
  • 17.44, endoscopic robotic-assisted procedure
  • 17.45, thoracoscopic robotic-assisted procedure
  • 17.49, other and unspecified robotic-assisted procedure
Codes in category 17.4x (robotic-assisted procedures) also include the following:
  • Computer-assisted robotic surgery
  • Computer-enhanced robotic surgery
  • Robotic procedure with computer assistance
  • Surgeon-controlled robotic surgery
However, the primary surgical procedure—a laparoscopic procedure—doesn’t change just because a surgeon uses a robotic-assist device. According to CMS and HIPAA defined code-sets, coders must report the primary surgical procedure with the appropriate ICD-9-CM Volume 3 procedure code first followed by the appropriate procedure code for the robotic assistance.
 
For example, when a patient undergoes a robotic-assisted laparoscopic total abdominal hysterectomy, report ICD-9-CM procedure code 68.41 followed by 17.42. The HCPCS procedure code-set provides code S2900 (surgical techniques requiring use of robotic surgical system) that coders can report in conjunction with a CPT® code for physician-based service claims.
 
ICD-10-PCS coding
Detailed documentation in the operative report will drive the assignment of the appropriate ICD-10-PCS code. The following ICD-10-PCS tables illustrate two different scenarios that could occur when a surgeon performs a laparoscopic robotic-assisted procedure.
 
First, consider ICD-10-PCS code 0UB94ZZ (percutaneous endoscopic excision of uterus).
Second, consider ICD-10-PCS code: 0UT94ZZ (percutaneous endoscopic resection of uterus).
 
(Click here to view the ICD-10-PCS tables)
 
The difference between 0UB94ZZ and 0UT94ZZ is that code 0UT94ZZ is a resection (i.e., cutting out or off, without replacement, all of a body part), and code 0UB94ZZ is an excision (i.e., cutting out or off, without replacement, a portion of a body part).
 
Surgeons must clearly document within the operative report whether the procedure involved the removal of all or a portion of the body part. However, coders must also have a thorough knowledge of anatomy to avoid any unnecessary queries and to prevent inaccurate code assignment. Reporting an incorrect ICD-10-PCS code could affect MS-DRG assignment which could, in turn, affect reimbursement. Coders must pay close attention to the following:
  • ICD-10-PCS guidelines and terminology
  • Anatomy of the body part involved in the procedure
  • Exactly what procedure the surgeon performed
  • How the surgeon performed the procedure
  • Whether the surgeon used robotic assistance to perform the procedure
However, what’s interesting is that ICD-10-PCS doesn’t specifically capture whether a procedure includes robotic assistance, nor does it address laparoscopic-assisted procedures. Coders can only choose from among the following surgical/procedure approaches:
  • Open
  • Percutaneous
  • Percutaneous endoscopic
  • Via natural or artificial opening
  • Via natural or artificial opening endoscopic
CMS defines percutaneous endoscopic in one of its ICD-10-CM/PCS educational slide presentations as “entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure.”
 
Thus, percutaneous endoscopic is the most appropriate approach for a hysterectomy involving a laparoscopic robotic device.
 
Operative report example
Consider the following excerpt from an operative report describing a robotic-assisted laparoscopic hysterectomy.
 
OPERATIVE REPORT: Total laparoscopic hysterectomy using the daVinci robotic® equipment.
 
The abdomen and vagina were prepped and draped in the normal sterile fashion. A Foley catheter was inserted. A long weighted speculum was placed into the vagina and an anterior wall retractor was placed into the vagina. The cervix was grasped with a single-tooth tenaculum and the uterus was sounded to 7.5 cm and was anterior.
 
The balloon manipulator was then properly placed. The balloon was filled to approximately 3 cc of saline. The cervical cup was placed around the cervix. A sterile glove filled with a lap pad was then placed inside the vagina to help with pneumoperitoneum. An 11 mm port was placed in the left upper quadrant just under the inferior costal margin. Adequate pneumoperitoneum was obtained. A 12 mm port was placed supraumbilically and the 12 mm trocar was placed through that port. The daVinci camera was then placed supraumbilically. 3 more ports were then placed. The 11 mm port was then placed in the left upper quadrant and there were two 8 mm ports that were placed 10 cm laterally to the umbilicus and 2 cm inferiorly. The daVinci robot was then docked in the normal fashion. The patient was placed in steep Trendelenburg positioning.
 
Inspection of the pelvis showed a normal uterus, ovaries and tubes. The right fallopian tube was cauterized using the PK bipolar cautery and was ligated using the hot shears. The utero-ovarian ligament was also coagulated and cut. The round ligament was coagulated and cut. A bladder flap was created with the hot shears and the bladder was dissected down from the cervix.
 
This entire procedure was then repeated on the left side. The blue balloon cuff was then identified and an incision was made in the cervicovaginal junction on top of the vaginal cuff. This was also repeated posteriorly. The incision was extended laterally, freeing the uterus from the surrounding vagina and including the excision of the cervix itself. The uterus was then morcellated and delivered posteriorly through the endocatch bag using the robotic assistant. The vaginal cuff was closed with four figure-of-eight sutures of 0 Vicryl. The ureters were identified bilaterally. The entire pelvis was hemostatic. The supraumbilical site was closed with a suture of 0 Vicryl. The skin was closed with 4- 0 Monocryl using subcuticular stitches. Steri-Strips were placed. The final needle, sponge and instrument count was correct. The patient tolerated the procedure well. Patient to the recovery room in good condition.
 
Using ICD-10-PCS, coders would report this procedure with code 0UB94ZZ. The operative note states that the surgeon removed the uterus but not the fallopian tubes or ovaries. It’s important for coders to note that the uterus includes the fallopian tubes and ovaries. These three structures are all considered one major organ. The surgeon used a percutaneous endoscopic approach (due to the laparoscopic surgical-assistance device). No other device or qualifier is noted in the record.
 
This example demonstrates that unlike ICD-9-CM procedural coding, ICD-10-PCS will include surgical robotic-assist devices as part of the approach rather than as a separately identifiable assistive device.
 
Note private payers
Third-party payers and insurance carriers aren’t governed under federal CMS guidelines. These private payers may provide their own policy coverage and guidelines for specific procedures that involve a robotic assist device.
 
When submitting claims to private or third-party payers, inquire in advance whether they prefer submission of HCPCS code S2900 in addition to the ICD-10-PCS code. As the ICD-10-CM/PCS implementation date approaches, these payers must provide clarification regarding coding and billing robotic-assisted procedures.
 
Editor’s note: Lori-Lynne A. Webb, CPC, CCS-P, CCP, is an independent coding consultant located in Melba, ID. Webb is also an AHIMA ICD-10-CM/PCS-accredited trainer and an AHIMA ACE Mentor. You can reach her at Webb Services, (208) 919-4246, or at lawebbcoding@aol.com



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