FAQs: Surgical Site Procedure Codes
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.
Q2: Where are the most current ICD-10-PCS and CPT procedure codes found?
The current list of procedure codes are found on the NHSN Surveillance for Surgical Site Infection (SSI) Events webpage in the “Supporting Materials” section of both Acute Care Facilities and Ambulatory Surgery Centers.
Q3: How should facility medical coders use the NHSN procedure code documents for classifying surgical procedures for patient charges?
The NHSN documents which list operative procedure codes and are posted on the SSI webpage, are not intended to be instructive to medical coders for assigning codes to surgical procedures. The documents are provided as a tool to NHSN users to assist with categorizing operative cases by procedure categories for reporting to NHSN and to standardize surgical procedures between facilities that choose to participate in NHSN.
Q4: Where is additional information found for NHSN procedure codes?
See Hot Topics-Quick Learn titled “ICD-10-PCS and CPT Transition”
Q5: When are codes updated and how are users notified of updates?
NHSN Procedure Codes are updated on an as needed basis.
Emails notifying NHSN users and vendors of updates are sent when updates are posted on the SSI webpage. The emails contain specific details of where the updates are posted and a summary of the updates.
Q6: Are ICD-10-PCS or CPT procedure codes required to enter SSI events into NHSN?
The use of ICD-10-PCS or CPT procedure codes is optional when entering SSI events into the NHSN application.
An ICD-10-PCS or CPT procedure code may be entered instead of (or in addition to) the NHSN Procedure Code name (e.g., COLO, HYST):
- If the ICD-10-PCS or CPT code is entered first, the NHSN Procedure Code name (e.g., COLO) will auto-fill by the application.
- If the NHSN Procedure Code name is entered first, the corresponding ICD-10-PCS or CPT operative procedure code may be manually entered or this field may be left blank.
Note: If there is a mismatch between the NHSN Procedure Code name and the ICD-10-PCS or CPT code, the application will produce an error message.
Q7: Are the 2017 CMS PCS codes included in the updated 2017 NHSN codes?
The updated CMS PCS codes that were released in Oct 2016 (CMS FY2017 final rule) are not included in the updated 2017 NHSN operative procedure codes. The codes from the CMS final rule will be reviewed and validated for inclusion in the 2018 NHSN code update. This lag time is due to time requirements for system development and related deadlines.
Professional coders within facilities may be assigning codes from the CMS FY2017 final rule to operative procedures performed within facilities on or after October 1, 2016, but facilities that are enrolled in and reporting through NHSN should only report procedures to NHSN based on the codes found in the documents posted on the NHSN SSI webpage and referenced in the current SSI Protocol.
Q8: A single trip to the OR can generate multiple procedure codes, how should a procedure that is coded as open and scope be entered into NHSN?
If a procedure is coded as open and scope then the procedure should be entered into NHSN as Scope =NO. The open designation is considered a higher risk procedure.
Q9: 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 this scope question. The fifth character indicates the approach to reach the procedure site:
- Value of zero (0) = an open approach.
- Value of four (4) = percutaneous endoscopic approach.
- Value of F = via natural or artificial opening with endoscopic assistance approach.
If the fifth character of the ICD-10-PCS code is a four (4) or F then the field for scope should be YES.
Note: If a procedure is coded as open and scope then the procedure should be entered into NHSN as Scope = NO. The open designation is considered a higher risk procedure.
Q10: When using ICD-10-PCS procedure codes there is no VSHN code for revisions of the distal shunts in the abdomen. Should these 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.
Q11: I don’t understand how hysterectomy codes are assigned – what determines when a procedure is categorized as a vaginal hysterectomy verses an abdominal hysterectomy? Are there definitions for each of these procedures?
ICD-10-PCS codes for hysterectomies should be assigned by professional coders based on the route the uterus is detached from its supporting structures. This is the same guidance that was in place and used for ICD-9 codes.
The definition for each NHSN operative procedure category can be found in the Index (purple tab) and on the individual procedure category worksheets of the NHSN “ICD-10-PCS Procedure Code Mapping” document. This document can be found in the Supporting Materials section of the NHSN Surveillance for Surgical Site Infection (SSI) Events webpage.