UHDDS - Uniform Hospital Discharge Data Set
Requires all significant procedures to be reported. Significant procedures meet any one of the following conditions: The procedure is surgical in nature; It carries an anesthetic risk; It carries a procedural risk; It requires specialized training.
Procedural Key Words
Surgery includes: incision, excision, destruction, amputation, introduction, insertion, endoscopy, repair, suturing, and manipulation.
Principal Procedure (1)
One performed for definitive treatment (rather than for diagnostic or exploratory purposes) or one that is necessary to care for a complication. .
Principal Procedure (2)
If two or more procedures appear to meet this definition, the one most related to the principal diagnosis is designated as the principal procedure.
Principal Procedure (3)
If two or more procedures are equally related to the principal diagnosis, the most resource intensive or complex procedure is usually designated as principal procedure.
Principal Procedure (4)
When more than one procedure is reported, the principal procedure should be identified by the one that relates to the principal diagnosis.
Are factors influencing health status and contact with health services. They are used when a procedure is canceled. They are used when a procedure is incomplete.
In surgical procedures, it is the name of surgeon or surgeons who developed the procedure. They are indexed in any of three ways: Under the eponym itself; Under the mainterm Operation; or Under a main term or subterm(s) that describes the operation.
Consist of three or four digits, with two digits preceding a decimal and one or two digits folowing the decimal. Only exception is for chapters, 00,13, 16 and 17.
Convention: "Code Also" (1)
This instructional note is used to indicate that an additional code should be assigned if the referenced procedure was performed. The need to assign codes for two closely related procedures is sometimes indicated in the index by the use of slanted brackets enclosing the seond code in the entry. Assign both codes as sequenced.
Convention: "Code Also" (2)
Used to advise the coder that individual components of a procedure, or two procedures that might be considered as a unit, must be coded.
Convention: "Code Also" (3)
Used to advise the coder that an additional code is to be assigned when certain adjunct procedures are performed, or certain equipment is used. This type of instruction is often found at the beginning of a category or subcategory and applies to all subdivisions.
Locating Procedure Terms
Mainterms in the Alphabetic Index for Procedures usually indicate the general type of procedure and can be found by words like: incision, excision, graft, implant, insertion, or removal. Some can be found by the name of the procedure with some subterms "with" and "without" and connecting words, "by" "for" and "to".
Excision of Organ or Lesion (1)
Removal of an organ is usually listed by site under the main terms Excision or Resection. When only a lesion of the organ is removed, it is necessary to check the main term Excision, the subterm lesion, and the more specific subterm that indicates the site of the lesion.
Excision of Organ or Lesion (2)
No entry for abdominal wall can be located under the main term Excision, but it can be located by referring to the subterm "lesion" under the main term Excision.
Some codes make a distinction to indicate if a procedure is performed unilaterally or bilaterally. This is not true for certain major procedures such as joint replacements. The code is assigned twice when the joint replacement is performed on both sides because the codes do not provide information that defines whether the procedure was unilateral or bilateral.
Coding Operative Approaches and Closures (1)
It is usually considered to be an integral part of a procedure. No code is assigned except in rare situations when the code for surgery does not imply the approach.
Coding Operative Approaches and Closures (2)
Codes are not assigned for closure or anesthesia.
Coding Operative Approaches and Closures (3)
The operative approach is coded when an opening into a body cavity is followed only by a diagnostic procedure such as a biopsy.
Coding Operative Approaches and Closures (4)
Ex: An Exploratory Laporatomy is performed for the purpose of removing an abdominal mass. When the cavity is opened, it is clear that a malignant lesion has spread through the abdominal cavity to the extent that a therapeutic resection is inappropriate. The surgeon removes samples of tissue to confirm the diagnosis and closes the abdominal incision. In this case, the laparotomy is coded and sequenced first (because it is a more significant procedure than a biopsy), and an additional code for the biopsy follows.
Laparoscopic, Thoracoscopic, and Arthroscopic Approaches (1)
These approaches are used for a number of procedures that were formerly only carried out by an open approach but they permit the removal of tissue or organs under videoscopic guidance through a very small incision and are less invasive, result in less trauma for the patient, the patient has an early discharge from the hospital, and a more rapid recovery.
Laparoscopic, Thoracoscopic, and Arthroscopic Approaches (2)
When these approaches are not successful, it is sometimes necessary to shift to an open approach in order to complete the surgery. When conversion to an open approach becomes necessary, only the open procedure is coded; no code is assigned for the laparoscopic, thoracoscopic, or arthroscopic approach.
Laparoscopic, Thoracoscopic, and Arthroscopic Approaches (3) Example
Code V64.41, Laparoscopic surgical procedure converted to open procedure; code V64.41, Thoracoscopic surgical procedure converted to open procedure; or code V64.43, Arthroscopic surgical procedure converted to open procedure. These codes would be assigned as additonal codes in this situation. Note: This advice applies even when no separate code indicating this approach is provided in ICD-9-CM.
Other Endoscopic Approaches
Other Endoscopic approaches are coded unless the Alphabetic Index directs otherwise or the code title indicates that the procedure was performed by endoscopy. When an endoscope is passed through more than one body cavity, the code for the endoscopy identifies the most distant site. Example: the procedure identified as esophagogastroduodenoscopy is classified as 45.13, Other endoscopy of small intestine.
Are the taking of tissue from a living person for the microscopic study. A biopsy code is not assigned when a lesion removed for therapeutic purposes is sent to the laboratory for examination. Even with the word biopsy describing it, this is not considered a biopsy. Biopsies can be closed or open.
Closed Biopsies (1)
Closed biopsies are performed: percutaneously, by needle, by brush, by aspiration and by endoscopy. Most biopsy codes have been revised to identify an endoscopic biopsy. A few codes don't make the distinction.
Closed Biopsies (2) Example 1
The code for biopsy for the urethra 58.23 does not indicate how it was performed. If it was done by Endoscopy, codes for both the endoscopic approach (sequenced first) and the biopsy are assigned.
Closed Biopsies (3)
In a brush biopsy, mucous or exfoliative tissue is removed by using a brush or bristle to collect cells for cytological examination. The procedure classification provides a separate code for a brush biopsy of a few anatomical locations otherwise, the code for closed biopsy of the specified site is assigned.
Closed Biopsies (4)
An aspiration biopsy collects cells for examination by aspriation; this procedure is also included in the code for closed biopsy.
Open Biopsies (1)
1. When an open biopsy is performed by way of an incision, the incision is implicit in the biopsy code. 2. When the approach is implied, (as with biopsy of the bone), no additional code for incision of the skin is required. 3. When a biopsy is incidental to the removal of other tissue during a procedure, both the procedure and the biopsy are coded, with the more definitive procedure sequenced first.
Open Biopsies (2) Example 1
A biopsy of the liver or pancreas may be performed when the main procedure is a colon resection or an appendectomy. A diagnostic exploratory procedure, like an exploratory transpleural thorascopy (34.21) is performed with the biopsy for diagnostic purposes (which is more than just the operative approach - thoracoscopic biopsy of the pleura, 34.20). BOTH THE BIOPSY AND THORACOSCOPY ARE CODED!
Open Biopsies (3) Example 2
A needed biopsy for the removal of a small sample of tissue performed during an open surgical procedure is coded as a closed biopsy even though the body cavity was opened. The type of biopsy is determined by the technique used to obtain tissue for study and in this connection "open" and "closed" do not refer to surgical approaches.to obtain access to internal organs. The code for the definitive procedure is sequenced first, with an additional code for the needle biopsy.
Open Biopsies (4) Example 3
A total Cholecystectomy was performed by means of abdominal incision. The pancreas is noted to be slightly enlarged, and a needle biopsy of the pancreas was performed to provide tissue for pathological examination. Code 51.22 Cholecystectomy and code 52.11, Closed (aspiration) (needle) (percutaneous) biopsy of pancreas.
Open Biopsies (5)
Occasionally a biopsy is performed immediately before the definitive procedure has begun. This permits the pathologist to perform a rapid-frozen section examination to determine whether a malignancy is present and allows the surgeon to modify the extent of surgery as necessary. Both the biopsy code and a code for the therapeutic procedure are assigned with the therapeutic code sequenced first.
Open Biopsies (6) Examples
Biopsy (open) of transverse colon for frozen section, followed by transverse colectomy, Code: 45.74 (transverse colectomy) + 45.26 (biopsy). Open biopsy of breast tumor for rapid-frozen section; no malignancy found; lumpectomy carried out, Code: 85.21 (Lumpectomy) + 85.12 (biopsy).
Coding Diagnosis-Related Procedures
Certain procedures are performed only for very specific conditions; care should be taken that the associated diagnosis code is also assigned. Ex: a solitary kidney can not be removed unless the patient has only a solitary kidney. There must be a related diagnosis code!
Coding Canceled Procedures (1)
A code from category V64, Persons encountering health services for specifc procedures not carried out, is assigned to account for the cancellation with no precedure code assigned. Note: a code from category V64 can not be assigned as the principal diagnosis.
Coding Canceled Procedures (2) Cancellation Reasons (1)
The patient may develop a condition that contraindicates the surgery (V64.1). Ex: A patient was admitted for a mastectomy because of carcinoma in situ of breast discovered on previous examination. Surgery was canceled because the patient was found to have an E. coli UTI. Code: 233.0 (carcinoma in situ) + 599.0 (UTI) + 041.49 (E. coli) + V64.1 (surgery canceled/contraindication).
Coding Canceled Procedures (3) Cancellation Reasons (2)
The patient may decide not to have the planned surgery (V64.2). Ex: A patient was admitted for a mastectomy because of carcinoma in stiu discovered. Before the procedure begun, the patient postposed. Code: 233.0 (carcinoma in situ) + V64.3 (surgery canceled/other reason).
Coding Canceled Procedures (4) Cancellation Reasons (3)
Problems in scheduling, illness of key staff, or some other situation may necessitate the cancellation of scheduled surgery. Ex: A patient was admitted for a mastectomy because of carcinoma in situ previously discovered. Surgery was canceled because the anesthesiologist assigned to the case was involved in an auto accident and no other anesthesiologist was available. Patient is discharged, to be readmitted for the mastectomy in 3 days. Code: 233.0 + V64.3.
Coding Incomplete Procedures (1)
Except for a code for the obstetrical procedure of failed forcepts (73.3), the procedure classification makes no provision for indicating that a procedure has not been completed. When a planned procedure has started but cannot be completed, it is coded to the extent to which it was actually performed.
Coding Incomplete Procedures (2) Principles to code by 1
If the incomplete procedure is incision only, code to the incision site.
Coding Incomplete Procedures (3) Principles to code by 2
If endoscopic approach is unable to reach site, code endoscopy only.
Coding Incomplete Procedures (4) Principles to code by 3
If cavity or space was entered, code to exploration of site.
Coding Incomplete Procedures (5) Example 1
Patient was admitted for transurethral removal of ureteral stone. Scope was passed as far as the bladder, but the surgeon was unable to pass it into the ureter. Code the cystoscopy only.
Coding Incomplete Procedures (6) Example 2
Patient was admitted for cholecystectomy with exploration of common duct. when the abdominal cavity was entered, extensive metastatic malignancy involving the stomach and duodenum with probably primary neoplasm in the pancreas was found. The procedure was discontinued, and the operative wound was closed. Assign only code 54.11, Exploratory laparotomy, because that was the extent of the procedure actually performed.
Coding Incomplete Procedures (7) Example 3
A patient was admitted for cholecystectomy. When the abdominal incision had been made, the patient suddenly developed an accelerating hypertension. Surgery was discontinued, the incision was closed, and the patient was returned to the nursing unit for care. Code only 54.0, Incision of the abdominal wall.
Coding Incomplete Procedures (8)
When a procedure is considered to have "failed" in that it did not achieve the hoped for result or because every objective of the procedure could not be accomplished, the procedure is coded as performed. Ex: Reocclusion of the coronary artery after the completion of a percutaneous coronary angioplasty makes it necessary to return to OR to perform a coronary artery bypass to correct the problem. The angioplasty might be described as failed but the procedure should be coded because it was performed.
Coding Shunt Procedures
For shunts, codes are assigned on the basis of the therapeutic intent and the procedure involved rather than on the name of the shut. Codes can be found in the index under the main terms Creation, Formation, Shunt, or Revision.
Coding a Ventriculoperitoneal Shunt (1)
VP-Shunts are inserted to drain cerebrospinal fluid to the peritoneal cavity when the normal cerebrospinal pathway is obstructed. When a procedure is described as a revision of a ventriculoperitoneal shunt, review the operative report to determine which portion of the shunt is involved. Only peritoneal site: code 54.95, Incision of the peritoneum; only the ventricular site: code 02.42; both sites code both.
Coding a Ventriculoperitoneal Shunt (2)
Sometimes, a VP-Shunt undergoes externalization because of recurrent infections. This involves excising the skin at the anterior chest wall. The shunt is externalized and connected to an external drainage system. Code 86.09, Other incision of skin and subcutaneous tissue.
Coding Stent Insertions (1)
Intravascular stents are tubular metal implants designed to restore blood flow by reopening or enlarging a blood vessel and maintaining patency. Stents are also valuable in treating threatened or abrupt vessel closure, thus reducing the need for emergency surgery.
Coding Stent Insertions (2)
Drug-eluting stents are a new type of stent created to address the common problem of vessel restenosis post stent insertion. Drug-eluting stent refers to a stent with an active drug (such as sirolimus, taxol, or paclitaxel) that is released in a controlled manner.
Coding Stent Insertions (3) Codes
The insertion of Conventional Stents, drug-covered or drug-coated stents is assigned to 36.06, Insertion of coronary artery stent(s), or 39.90, Insertion of non-drug-eluting peripheral vessel stent(s). However, the insertion of Drug Eluting Stents is coded to 36.07, Insertion of drug-eluting coronary arty stent(s) or 00.55, Insertion of drug-eluting stent(s) of other peripheral vessels.
Coding Stent Insertions (4) Coronary
Coronary angioplasty performed by any technique is inherent in the placement of a coronary stent; the appropriate code for the angioplasty (00.66 or 36.03) is assigned with an additional code of (36.06 or 36.07) for the stent insertion.
Coding Stent Insertion (5) Peripheral
Peripheral vessel stent insertion is coded (39.90 or 00.55) non-drug-eluted or drug-eluted.
Coding Stent Insertion (6) Other
Codes for other intravascular stent insertions: carotid artery 00.63; other extrcranial arteries 00.64; intracranial vessels 00.65.
Coding Stent Insertion (7) Additonal Codes
The number of vessels treated (00.40-00.43) and the number of stents inserted (00.45-00.48) if multiple stents are inserted. Note: these codes apply to both coronary and peripheral vessels. Also 00.44, Procedure on vessel bifurcation is used to identify the presence of a vessel bifurcation and is only used once per operative episode regardless of the number of vessel bifurcations.
Coding Stent Insertion (8) Other Locations
Ex: Code 51.43 for insertion of a stent into a bile duct; if the insertion is by endoscopy, code 51.87. Code 51.98 for pancreatic transhepatic stent insertion. code 46.87 for insertion of a colonic stent; if the insertion is performed via endoscopy, code 46.86.
Stereotactic Radiosurgery (1)
Performed as a treatment for brain lesions and tumors such as acoustic neuroma, pituitary adenoma, and skull based meningioma, and for treating atriovenous malformations and has been used in the treatment of functional disorders such as Parkinson's disease, epilepsy, and intractable pain.
Stereotactic Radiosurgery (2) Treatment
Patient is taken to the radiology department where a stereotactic head frame is placed to provide for target coordination determination. Code 93.59, Other immobilization, pressue, and attention to would. CT or MRI or angiography are then done. The imaging is used to develop an individual's radiation dosage plan, once imaging is complete, the patient is placed in the head frame and radiation is focused on the lesion. Subcategory 92.3, Stereotactic radiosurgery, has been explanded by added a fourth digit (92.30-92.39) that indicates the source of radiation.
Computer Assisted Surgery (CAS) (1)
An adjunctive surgical process using imaging, markers, reference frames, intraoperative sensing, and computer workstations. CAS is used to increase visualization and precise navigation with minimally invasive approaches. The planning involved creation of t3-D graphic models linked to the patients anatomy then linked to the surgical procedure through an intraoperative computer workstation.
Computer Assisted Surgery (CAS) (2)
Computer assisted surgeries are reported with the code for the specific diagnostic or therapeutic procedure performed, along with a code from subcategory 00.3, Computer assisted surgery [CAS]. It is classified by the different imaging modalities used such as: CT 00.31, MRI 00.32, Fluoroscopy 00.33, Imageless CAS 00.34, Multiple datasets 00.35, and other Modalities 00.39.
Robotic Assisted Procedures (1)
A minimally invasive surgery, whereby robotic tools allow surgeons to operate through small incisions using an endoscope. Surgeons do not manipulate endoscopic tools with their hands he/she sits at a console using a joystick. These procedures include use of a computer console with 3-D imaging and instrumentation combined with the use of robotic arms, device(s), or system(s) a the time of the procedure.
Robotic Assisted Procedures (2)
Classified on the basis of the approach used such as: open 17.41, laparoscopic 17.42, percutaneous 17.43, endoscopic 17.44, thoracoscopic 17.45, and other/unspecified 17.49. Can be used with procedures like: prostatectomies, hysterectomies, and cholecystectomies. Because these codes represent the use of robotic assistance but do not specify the actual surgical procedure performed, the code for the primary surgical procedure should be assigned first.