Other acute postprocedural pain. G89.18 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
ICD-10-PCS Coding: Hysterectomy. When reading through documentation in an operative report for a hysterectomy, for the ‘Procedure Performed’, a ‘TAH-BSO, and Omenectomy’ is performed. As with all operative reports, there are guidelines that should be followed when determining the appropriate ICD-10-PCS codes. The first is identifying ‘TAH-BSO’.
The ICD-10-PCS coding for the TAH-BSO with Omenectomy would be: Uterus: 0UT90ZZ; Fallopian tubes, bilateral 0UT70ZZ; Ovaries, bilateral 0UT20ZZ; Cervix (if performed) Complete 0UTC0ZZ; Partial 0UBC0ZZ; Omentum Greater Complete 0DTS0ZZ; Partial 0DBS0ZZ; Lesser Complete 0DTT0ZZ; Partial 0DBT0ZZ
Yes, it is important to accurately code the diagnosis. The ICD-10-CM guidelines for postop/aftercare include the following:
Z90. 710 - Acquired absence of both cervix and uterus | ICD-10-CM.
ICD-10-CM Code for Encounter for surgical aftercare following surgery on specified body systems Z48. 81.
81: Encounter for surgical aftercare following surgery on specified body systems.
In CPT 2008, the American Medical Association (AMA) published the total laparoscopic hysterectomy (TLH) set of codes (58570-58573). This, in addition to the laparoscopic radical hysterectomy with pelvic lymphadenectomy code (58548), is the third set of CPT codes addressing the laparoscopic approach to hysterectomy.
Use Z codes to code for surgical aftercare. Z47. 89, Encounter for other orthopedic aftercare, and. Z47. 1, Aftercare following joint replacement surgery.
Post-operative visits should be reported with CPT code 99024 when the visit is furnished on the same day as an unrelated E/M service (billed with modifier 24).
Z48. 812 Encntr for surgical aftcr following surgery on the circ sys - ICD-10-CM Diagnosis Codes.
Aftercare visit codes are assigned in situations in which the initial treatment of a disease has been performed but the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease.
Follow-up. The difference between aftercare and follow-up is the type of care the physician renders. Aftercare implies the physician is providing related treatment for the patient after a surgery or procedure. Follow-up, on the other hand, is surveillance of the patient to make sure all is going well.
(2008) , hysterectomies were defined using ICD-9-CM procedure codes 68.4, 68.5, or 68.9 in hospital discharge abstracts data.
The code for a total abdominal hysterectomy is: 0UT90ZZ Resection of uterus, open approach. In this example the “Z No Qualifier” is indicating that both the uterus and cervix are removed. The code for a laparoscopic supracervical hysterectomy is: 0UT94ZL Resection of uterus, percutaneous endoscopic, supracervical.
58150CPT® Code 58150 in section: Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s)
For the omenectomy, the omentum is listed in the Gastrointestinal System section of PCS. This seems to be the most problematic of the procedures as much of the documentation seen is unclear. Documentation needs to state whether the greater omentum or the lesser omentum was operated on and if the procedure performed was an ‘Excision’ or ‘Resection’. If not stated, the provider will need to be queried for clarification.
During many hysterectomies, although not listed in the ‘Procedures Performed’, the cervix or part of the cervix may be removed. When reading through the operative report, whether the cervix is partially excised or completely removed will determine ICD-10-PCS code selection. If partially excised, review the codes in the Female Reproductive System, under the root word ‘Excision’; if the cervix is completely removed, it would be a ‘Resection’.