ICD-10-PCS Surgical Approach Definitions and Guidelines

The 5th character of an ICD-10-PCS code reports the approach or method used to reach and visualize the operative site to facilitate performance of a procedure. There are 7 approach options in ICD-10-PCS. Familiarity with the work and technique described by each of these 7 options is essential to ensuring the coder is selecting the most correct approach to report the work performed by the physician.

External

ICD-10-PCS Definition

Procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane. 

Examples

• Laceration repair of skin or mucous membranes
• Excisional debridement of skin only

Procedures performed within an orifice on structures that are visible without the aid of any instrumentation are coded to the approach External (see ICD-10-PCS Coding Guideline B5.3a).

Example

• Tonsillectomy

Procedures performed indirectly by the application of external force through the intervening body layers are coded to the approach External (see ICD-10-PCS Coding Guideline B5.3b).

Example

• Closed fracture reduction

Open

ICD-10-PCS Definition

Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure. 

The key here is exposure of the procedure site. The physician should be able to visualize the site of the procedure without the aid of instrumentation.

Example

• Repair of second-degree obstetrical laceration of the perineum

This would be coded as an open approach since the laceration has cut through the external body layers exposing the muscle.

Procedures performed using the open approach with percutaneous endoscopic assistance or hand-assisted laparoscopy are coded as open.

Examples

• Laparoscopic-assisted bowel resection/excision (see ICD-10-PCS Coding Guideline B5.2a)
• Nephroureterectomy via hand-assisted laparoscopy (see AHA Coding Clinic 3rd Qtr. 2014, page 16)

Note: A small nick in the skin or small incision made in the skin to facilitate a percutaneous procedure does not constitute an open approach.

Percutaneous

ICD-10-PCS Definition

Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure.

This approach requires the use of instrumentation and visualization of the site of the procedure is not included in this definition. For percutaneous procedures that require visualization of the procedure site, see the approach Percutaneous Endoscopic.

Examples

• Arterial/venous catheter placement
• Coil embolization of artery
• Drainage of subdural hemorrhage via burr hole
• Laser trabeculoplasty
• PTCA of the coronary artery
• Amniocentesis
• Needle biopsy

Procedures performed percutaneously via a device placed for the procedure are coded to the approach Percutaneous (see ICD-10-PCS Coding Guideline B5.4)

Example

• Fragmentation of kidney stone performed via percutaneous nephrostomy

Percutaneous Endoscopic

ICD-10-PCS Definition

Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure. 

Examples

• Knee arthroscopy
• Laparoscopic cholecystectomy

This approach is assigned when hand-assistance is used with a percutaneous endoscopic approach or if an incision is made or extended to assist in

• Removal of a body part
• Anastomosis of a tubular body part
• Temporary exteriorization (to bring out of the body) of a body structure

See ICD-10-PCS Coding Guideline B5.2b.

Examples

• Laparoscopic nephrectomy with midline incision for removing the resected kidney
• Laparoscopic sigmoid colectomy with extension of stapling port for removal of specimen and direct anastomosis
• Hand-assisted laparoscopic sigmoid colon resection with exteriorization of a segment of the colon for removal of specimen with return of colon back into abdominal cavity

In several ICD-10-PCS code tables, the use of hand-assistance is indicated by the qualifier character with the assignment of value G Hand-Assisted. This qualifier is only available with the approach value of 4 Percutaneous Endoscopic.

Via Natural or Artificial Opening

ICD-10-PCS Definition

Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure.

Examples

• Monitoring of fetal heart rate
• Urinary pressure monitoring
• Cardiac catheterization to measure cardiac pressure/output

This approach requires the use of instrumentation to reach the site of the procedure. Visualization is not included in this definition. For procedures performed through a natural or artificial opening that require visualization of the procedure site, see the approach Via Natural or Artificial Opening Endoscopic.

Via Natural or Artificial Opening Endoscopic

ICD-10-PCS Definition

Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure.

Examples

• EGD with gastric biopsy
• Hysteroscopy with dilation and curettage
• Diagnostic/therapeutic colonoscopy

Performance of these procedures requires the use of a scope that allows the physician to visualize the operative site.

Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance

ICD-10-PCS Definition

Entry of instrumentation through a natural or artificial external opening and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure.

This approach combines features of the Via Natural or Artificial Opening approach and the Percutaneous Endoscopic Approach. This approach requires the insertion of instrumentation through both an external opening and percutaneously through a minor puncture or incision.

This approach is only available in three ICD-10-PCS code tables

• 0DB Gastrointestinal, Excision
• 0DT Gastrointestinal, Resection
• 0UT Female Reproductive, Resection

Examples

• Laparoscopic assisted vaginal hysterectomy (LAVH)
• Laparoscopic assisted intestinal pull-through

These are just a few examples of procedures performed via each type of approach. Careful review and application of the details of the technique reported with each approach will aid the coder in selecting the correct approach value for any procedure they encounter.

For the past 30 years, HIA has been the leading provider of compliance audits, coding support services and clinical documentation audit services for hospitals, ambulatory surgery centers, physician groups and other healthcare entities. HIA offers PRN support as well as total outsource support.

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.