FAQs: Surgical Site Procedure Codes

ICD-10-PCS code characters

Q1: When entering the following code OUT90ZZ, the application gives an error?

ICD-10 codes do not include the letters O (oh) or I (eye) as these are easily mistaken for the numbers 0 (zero) and 1 (one).  ICD-10 code OUT90ZZ should be entered as 0UT90ZZ and 0X6I0ZZ should be entered as 0X610ZZ.


List of Operative Procedure Codes

Q2: Where are the most current ICD-10-PCS and CPT operative procedure codes found?


NHSN Procedure Code Documents

Q3: How should facility medical coders use the NHSN procedure code documents for classifying surgical procedures for patient charges?

The NHSN operative procedure code documents, posted on the NHSN site, are not intended to be instructive to medical coders for assigning procedure codes to surgical procedures.  The documents are provided as a tool to assist NHSN users participating in SSI reporting with categorizing operative procedures by NHSN procedure categories and to standardize the reporting of surgical procedures between facilities.


Updates to Procedure Codes

Q4: When are codes updated and how are users notified of updates?

NHSN operative procedure codes are reviewed and updated annually and as needed.

Communication regarding updates to the operative procedure codes are sent via email to individuals and vendors enrolled in NHSN.  The emails contain specific details about the updates; therefore, it is critical that all NHSN users review their NHSN user contact information on a regular basis and update as necessary.


Using Procedure Codes

Q5: Are ICD-10-PCS or CPT procedure codes required to enter SSI events into NHSN?

The use of the NHSN operative procedure codes (ICD-10-PCS or CPT) is required to determine the correct NHSN operative procedure category but entering the operative procedure code into the NHSN application remains optional.


Scope

Q6: A single trip to the Operating Room can generate multiple procedure codes, how should a procedure that is assigned a procedure code with an open approach and a procedure code with a scope approach be entered into NHSN?

If a procedure is assigned a procedure code with an open approach and a procedure code with a scope approach then the procedure should be entered into NHSN as Scope = NO. The Open Approach indicates a higher risk.

 

Q7: Using the ICD-10-PCS codes, is there a quick way to know when to select “Scope = YES”?

ICD-10-PCS codes can be helpful in answering the scope question. The fifth character indicates the approach to reach the operative procedure site:

ICD-10 5th Character Approach NHSN Scope Designation
ICD-10-PCS code for fifth character inidcates the approach
0 Open NO
3 Percutaneous (Included only in CRAN and VSHN categories- procedures with BURR holes) NO
4 Percutaneous endoscopic YES
7 Via natural or artificial opening NO
8 Via natural or artificial opening with endoscopic NO
F Via natural or artificial opening with percutaneous endoscopic assistance YES

 

If the fifth character of the ICD-10-PCS procedure code is a four (4) or F then the field for scope should be YES.


Shunt Revisions

Q8: When using ICD-10-PCS procedure codes there is no VSHN code for revisions of the distal shunts in the abdomen.  Should the procedure be entered since it was a shunt revision?

Within the ICD-9 code system there were specific revision codes for procedures that involved distal shunt replacement or revision of the distal catheter, there are no codes within the ICD-10-PCS code system that are specific for this type of procedure.

In cases such as this, if it is known from the surgical / intra-operative report that the procedure is associated with a shunt revision, then it should be entered into NHSN as a VSHN procedure.


HYST

Q9: When reporting hysterectomy procedures to NHSN, what determines when a procedure is categorized as a vaginal hysterectomy verses an abdominal hysterectomy? Are there definitions for each of these procedures?

A trained medical coder, using current medical coding guidelines and conventions, should assign the correct procedure code (CPT and ICD-10-PCS) to the hysterectomy procedure.

For the purpose of SSI reporting, the NHSN HYST – abdominal hysterectomy operative procedure category includes hysterectomy procedures / codes that involve an incision into the abdomen, including trocar insertion.

The hysterectomy procedure approach (5th character of the ICD-10 operative procedure code assigned by a medical coder) identifies whether an abdominal incision was made and determines if the procedure is categorized as a NHSN HYST or VHYS.

The definition of each NHSN operative procedure category is listed in the NHSN “ICD-10-PCS Procedure Code Mapping” document.  This document can be found in the Supporting Materials section on the NHSN Surveillance for Surgical Site Infection (SSI) Events web page.


CPT HYST Procedures

Q10: Why are there CPT codes that include “vaginal hysterectomy” in the procedure description included in the HYST-abdominal hysterectomy procedure category?

Hysterectomy procedures / codes that involve an incision into the abdomen, including trocar insertion are categorized as NHSN HYST – abdominal hysterectomy procedures; therefore, a few of the CPT codes that include “laparoscopy, surgical, with vaginal hysterectomy” in the procedure description are included in the HYST procedure category.  The use of a laparoscopic approach indicates that an incision was made into the abdomen.

Procedure Category Procedure Code Procedure Code Description Code Status
ICD-10-PCS code for fifth character inidcates the approach
HYST 58550 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less Moved from VHYS
HYST  58552 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tubes(s) and /or ovary(s) Moved from VHYS
HYST  58553 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g Moved from VHYS
HYST  58554 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Moved from VHYS