FAQs: Surgical Site Procedure Codes
ICD-10-PCS code characters
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
- The current lists of operative procedure codes are found on the NHSN Surgical Site Infection (SSI) Events web page.
- Procedure code documents for the past two years can be found on the NHSN Data Validation’s web page.
NHSN Procedure Code Documents
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
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
The use of the NHSN operative procedure codes (ICD-10-PCS and/ CPT) is required to determine the correct NHSN operative procedure category but entering the operative procedure code into the NHSN application remains optional.
NHSN operative procedure reporting is based on the operative procedure code(s) assigned by a trained medical coder. There are several instructions, guidelines and conventions that govern how and when medical codes are assigned. For questions related to correct procedure code assignment consult with your facility medical coder.
Scope is reported based on the primary incision site. If an open and scope code is assigned to procedures in the same NHSN procedure category, then the procedure should be reported to NHSN as Scope = NO. The open designation is considered a higher risk procedure.
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
|NHSN Scope Designation
|Percutaneous (Included only in CRAN and VSHN categories- procedures with BURR holes)
|Via natural or artificial opening
|Via natural or artificial opening with endoscopic
|Via natural or artificial opening with percutaneous endoscopic assistance
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.
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 to NHSN Operative Procedure Codes” document. This document can be found on the NHSN Surveillance for Surgical Site Infection (SSI) Events web page under “Operative Procedure Code Documents”.
CPT HYST Procedures
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 Code Description
|Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less
|Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tubes(s) and /or ovary(s)
|Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g
|Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)