Surgical Approaches - Open vs. Percutaneous vs. External

Definitions/Explanations...

Open approach

is cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure.  If procedures are performed using the open approach with percutaneous endoscopic assistance or hand-assisted laparoscopy they are coded as open.  An example of this is laparoscopic-assisted bowel resection/excision and nephroureterectomy via hand-assisted laparoscopy. A different example of an open approach is 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.

A small nick in the skin or small incision made in the skin does not constitute an open approach. These are necessary for percutaneous procedures.

Percutaneous endoscopic approach

is entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach and visualize the site of the procedure.  Examples include knee arthroscopy and laparoscopic cholecystectomy.  This approach includes procedures whereby the procedure is performed entirely by percutaneous endoscopic approach.  Percutaneous endoscopic-assisted procedures are coded to the open approach as stated above.

Percutaneous approach

is entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach the site of the procedure. Examples of percutaneous approach are arterial/venous catheter placement, coil embolization of artery, drainage of subdural hemorrhage via burr hole, laser trabeculoplasty, and PTCA of the coronary artery.

External approach

is for 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 of external approach procedures are closed fracture reduction, laceration repair of skin or mucous membranes, and excisional debridement of skin only.

Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance

is for limited procedures only in the Female Reproductive System.  Defined as “entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure, 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.”  One example is an “LAVH” or laparoscopic assisted vaginal hysterectomy.

These are but a few examples of these selected approaches. There are also multiple examples in the ICD-10-PCS Reference Manual to help you better understand the procedure approaches.

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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.