Question

INDICATIONS FOR SURGERY: A 34-year-old female presents with severe abdominal pain. After examination was completed and ultrasound results were reviewed, it was determined that patient had an ectopic pregnancy and surgical intervention was needed. PROCEDURE: Patient was taken to the operating room, and after general anesthesia was induced, she was prepped and draped in the usual sterile fashion. Examination was performed after anesthesia, which showed a normal-sized, nontender uterus, a left adnexal mass, and a fullness in the vagina, all consistent with hyperperitoneum. A 10-mm trocar was inserted directly into the abdomen through a small incision in the umbilicus. Using 3.5 liters of carbon dioxide, a pneumoperitoneum was created. The hemoperitoneum was noticed, and another 10-mm trocar was placed in a small suprapubic incision. Two 5-mm ports were also placed under direct visualization in both the right and left lower quadrants. With an irrigator and aspirator, the hemoperitoneum was reduced. The left fallopian tube was noted to be almost to the point of rupture due to a mass in the tube. The fallopian tube was distended beyond repair; so this needed to be removed. The tube was tied off and removed with its contents through an Endo Catch bag through the 10-mm port. Inspection of the abdomen noted no other problems; adequate hemostasis was noted, and ports were removed. Defects were closed with 0 Vicryl, and the skin was closed with 4-0 Dexon. She was sent to the recovery room in stable condition.

ICD-10-PCS Code Assignment is: ___________ and ____________

Answer 1

Answer:

ICD-10-PCS Code Assignment is:

O00.1 Tubal Pregnancy

10T24ZZ Resection of ectopic products of conception, percutaneous endoscopic

0UB64ZZ Excision of left fallopian tube, percutaneous endoscopic

Rationale: Only the ICD-10-CM code for tubal pregnancy is assigned and a second code from category Z3A, weeks of gestation is not assigned. There is an instructional note at the beginning of Chapter 15 which applies to all codes to assign an additional from category Z3A to identify the weeks of gestation. However, the 3rd Q 2014 Coding Clinic indicated that a code from category Z3A should not be assigned if the pregnancy is outside the uterus or otherwise nonviable.

Because the procedure is being performed to remove ectopic products of conception, the code should come from the Obstetrics section of ICD-10-PCS. The entire pregnancy was removed making the root operation Resection. The only body part character available in this table is Products of Conception, Ectopic. A second code should be reported to address the removal of a part of the left fallopian tube, not just the products of conception