Today we are going to discuss when it is appropriate to assign more than one code to a procedure when it is done under the same episode of care.
This week’s coding problem
- Attempted laparoscopy with ablation of endometrium was made. However, due to some unexpected complications, this procedure had to be converted to open ablation of endometrium.
- 0U5B0ZZ; 0UJD4ZZ
Problem #1, Part 1: An attempted laparoscopy with ablation of endometrium was made. However, due to some unexpected complications, this procedure had to be converted to open ablation of endometrium.
- To Locate Part 1: PCS Index > Ablation > see Destruction > Endometrium > 0U5B> Locate table 0U5 and go across the row to finish building the code:
Destruction of Endometrium, Open Approach
- If you know that ablation is a form of destruction, don’t waste your time by going to Ablation first.
- Destruction is defined as “Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent.”
- Guideline B3.2.d.: During the same operative episode, multiple procedures are coded if:
- The intended root operation is attempted using one approach, but is converted to a different approach. Code both the discontinued procedure to the root operation performed and the definitive procedure. We are coding the definitive procedure first. The procedure started out using a laparoscope but had to be converted to an open approach to complete destruction of the endometrium.
- The above-referenced table is coded to open approach.
- Since we have to code the discontinued laparoscopy based on guideline B.3.2.d., here we go:
- To Locate, Part 2: PCS Index > Inspection > Uterus > 0UJD > Locate table 0UJ and go across the row to finish building the code.
Inspection of Uterus, Percutaneous Endoscopic Approach
- This is the first part of the procedure in which they inserted the laparoscope.
- The approach is Percutaneous Endoscopic because a laparoscope was used.
- Inspection is one of the new terms and is defined as visually and/or manually exploring a body part.