Health Information Management

Take Control of post-operative bleeding in ICD-10-PCS

HIM-HIPAA Insider, April 21, 2014

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A patient undergoes a hysterectomy and experiences post-procedural bleeding. The surgeon cauterizes the bleed and evacuates a blood clot.

In ICD-10-PCS, how do you code the cauterization? With the root operation Control (third character 3).

Control (stopping, or attempting to stop, postprocedural bleeding) in ICD-10-PCS represents a very limited set of procedures. You will use root operation Control when the only objective of the procedure is to stop hemorrhaging after a procedure.


Procedures that fall under Control include:
  • Irrigating or evacuating a hematoma at the operative site
  • Ligation of arterial bleeders
  • Cautery with blood clot evacuation
  • Drainage at previous operative site to stop bleeding

The site of the bleeding is coded as an anatomical region and not to a specific body part. For our patient with the post-hysterectomy bleed, we would report 0W3R8ZZ (hysteroscopy with cautery of post-hysterectomy oozing and evacuation of clot).

Other Control procedures include:
  • 0X3F0ZZ, open exploration and ligation of post-op arterial bleeder, left forearm
  • 0W3H0ZZ, control of post-operative retroperitoneal bleeding via laparotomy
  • 0W3C0ZZ, reopening of thoracotomy site with drainage and control of post-op hemopericardium
  • 0Y3F4ZZ, arthroscopy with drainage of hemarthrosis at previous operative site, right knee

What happens when the physician needs to perform a more involved procedure to stop the bleeding? For example, a physician needs to resect the spleen in order to control post-procedural bleeding. Do you report a
Control procedure, a Resection procedure, or both?

According to ICD-10-PCS guideline B3.7:

If an attempt to stop post-procedural bleeding is initially unsuccessful, and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded instead of Control.

So for our patient who lost her spleen, we would report 07TP0ZZ (resection of spleen, open approach) or 07TP4ZZ (resection of spleen, percutaneous endoscopic approach).
 
This article originally appeared on HCPro’s ICD-10 Trainer blog.



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