Operation:

1. Total abdominal hysterectomy;
2. Bilateral salpingo-oophorectomy;
3. Liver biopsy

Procedure Detail:

The patient was placed in the supine position under general anesthesia. The abdomen was prepped and draped in the usual sterile fashion. A Pfannenstiel incision was made in the area of the patient’s previous Pfannenstiel incision and this was carried down through the subcutaneous fat to the fascia, which was incised transversely. The fascia was dissected off of the underlying rectus muscles. Bleeders were coagulated. The rectus muscles were separated from the fascia above. There was some scarring of the fascia, particularly on the patient’s left side. The rectus muscles were parted. The peritoneum was identified. Entry was made into the peritoneal cavity without difficulty. The peritoneal incision was carried inferiorly to superiorly. At this point, I explored the upper abdomen and performed a Tru-Cut needle biopsy of the left lobe of the liver without difficulty.

Coagulation was utilized to control bleeding. Hemostasis was established and at the end of the procedure, the area of the biopsy site was reevaluated and was noted to be hemostatic. A moist lap was used against this area for compression during the remaining portion of the case, and this lap was removed prior to closing the abdomen.

At this time, the O’Conner-O’Sullivan retractor was put in place. A series of moist laps were used to pack the bowel out of the operative field. The uterus was noted to be markedly retroverted with marked pelvic congestion and the large infundibulopelvic vessels were noted, as well as the broad ligament. The round ligaments were bilaterally doubly Heaney clamped, cut, and suture ligated with 0 Vicryl. The anterior leaf of the broad ligament and posterior leaf of the broad ligament were sharply dissected. Hemostasis was accomplished by coagulation.

The quadrangular space was bluntly penetrated bilaterally. Two ligatures of 0 Vicryl were put in place along the infundibulopelvic vessels after taking care to assure the location of the ureters was out of the operative field. This area was then clamped and cut. Hemostasis along the infundibulopelvic pedicle was noted to be good. The ovaries and fallopian tubes were bilaterally removed. There was a right ovarian cyst with multiple smaller cysts noted on the right ovary. The left ovary appeared to be somewhat scarred and was small and reflective of a previous partial oophorectomy, which was performed many years ago on this ovary. The anterior leaf of the broad ligament was sharply dissected. The bladder was sharply dissected off the anterior aspect of the lower uterine segment.

The uterine vessels were bilaterally doubly Heaney clamped, cut, and suture ligated with 0 Vicryl. The remaining portions of the uterine vessels and cardinal ligaments were singularly Ochsner clamped, cut, and suture ligated with 0 Vicryl. The bladder was further dissected off of the anterior aspect of the lower uterine segment. The uterosacral ligaments were singularly Ochsner clamped, cut, and suture ligated with 0 Vicryl, which was held. Entrance was made into the lateral aspects of the vagina. The cervix was sharply dissected away from the vaginal mucosa and the uterine body (uterus and cervix) were removed in total. Aldrich angle sutures were put in place bilaterally. The anterior and posterior vaginal cuffs were approximated with a series of interrupted figure-of-eight sutures utilizing 0 Vicryl. Hemostasis was noted to be good. Copious irrigation was carried out with good evidence of hemostasis in the pelvis. At this time, the O’Conner-O’Sullivan and lap squares were removed. Further visualization of the liver biopsy site was noted and found to be hemostatic.

At this point, the abdomen was closed in a series of layers. The peritoneum was closed with 0 Vicryl in a running fashion. The rectus muscles were reapproximated with 0 Vicryl interrupted mattress sutures. The fascia was closed with #1 Vicryl in a running fashion. Small bleeders were coagulated in the subcutaneous fat. The skin was closed with staples. A sterile dressing was applied. The patient will be sent to Recovery following the procedure. Sponge, lap, and instrument counts were correct times two.

Case Study 1

0UT90ZZ Resection, Uterus (0UT9): Hysterectomy, see Resection, Uterus

0UT20ZZ Resection, Ovary, Bilateral (0UT2)

0UT70ZZ Resection, Fallopian Tubes, Bilateral (0UT7)

0FB20ZX Excision, Liver, Left Lobe (0FB2) Biopsy, see Excision with qualifier, Diagnostic;

Rationale: The ICD-10-PCS Root Operation Guidelines for coding multiple procedures state that if the same root operation is performed on different body parts as defined by distinct values of the body part character, each should be coded separately (B3.2a).

During this procedure, three distinct body parts were removed: uterus, both ovaries, and both fallopian tubes, and therefore, they should be coded separately. The root operation Resection is selected since the entire uterus and cervix is removed during a total abdominal hysterectomy.

Removal of bilateral ovaries is coded to 0UT20ZZ with the body part value of 2 indicating bilateral ovaries. Removal of bilateral fallopian tubes is coded to 0UT70ZZ with the body part value of 7 indicating bilateral fallopian tubes.

ICD-10-PCS Coding Guideline B4.3 states that bilateral body part values are available for a limited number of body parts. If the identical procedure is performed on contralateral body parts, and a bilateral body part value exists for that body part, a single procedure is coded using the bilateral body part value.

For all three of these codes, the approach is 0 for open. The liver biopsy is coded to 0FB20ZX.

The root operation for the biopsy is Excision (B) since only a portion of the liver is removed. The approach for the liver biopsy is Open.

In ICD-10-PCS, the approach is the technique used to reach the site of the procedure. In this case, the laparotomy was the technique used to reach the liver.

The needle was simply the instrument used to obtain the sample. The qualifier for the liver biopsy is Diagnostic (X), which is used to identify excision procedures that are biopsies.

Additionally, AHA Coding Clinic®, Fourth Quarter 2017 states a total hysterectomy includes the removal of the uterus and cervix and only one code is needed.

You do not code control of bleeding, as this is not specified as what would be normal for this surgery.