ICD-10-PCS Coding for Ex Utero Intrapartum (EXIT) Procedures

Ex utero intrapartum (EXIT) procedures present unique ICD-10-PCS coding challenges due to their timing, anatomy, and classification as procedures on the products of conception. This Coding Tip explains how to accurately code EXIT procedures using official Coding Clinic guidance, including correct section selection, root operation assignment, and reporting requirements. Medical coders will gain practical insight into applying ICD-10-PCS rules confidently for complex obstetric and fetal surgery scenarios.

An ex utero intrapartum or EXIT procedure is one where a fetus is partially delivered through a cesarean section incision then undergoes intubation and surgery to secure its airway, prior to completion of the delivery. Once the surgical procedure is completed, the umbilical cord is clamped and cut, the remainder of the fetus is delivered and the cesarean proceeds as usual. Using this surgical approach allows the newborn to remain connected to the placenta, to continue access to oxygen and nutrients during the procedure which minimizes risk of hypoxia or ischemic brain injury.

Conditions Commonly Treated With Ex Utero Intrapartum Procedures

The conditions treated with an ex utero intrapartum approach are related to fetal lung or heart function. These conditions include:

• congenital high airway obstruction syndrome
• congenital pulmonary airway malformations
• compressive airway tumors or masses
• cervical teratomas
• cystic hygromas
• diaphragmatic hernias
• large lung masses
• heart problems

ICD-10-PCS Coding Considerations

Ex utero intrapartum procedures are unique in that it seems that you have two patients being operated on at the same time, with one procedure being interrupted by the performance of another. This raises some questions when selecting the correct characters to build an appropriate ICD-10-PCS code. Fortunately, there is official guidance on how to code these procedures. The following points are based on the advice in Coding Clinic for ICD-10-CM/PCS, Second Quarter 2021: Page 21

• Because the fetus has not been fully delivered, this is considered a procedure on the products of conception.
• Procedures on the products of conception are reported from the Obstetrics section of ICD-10-PCS (see ICD-10-PCS coding guideline C1).
• The relevant body part value from the Obstetrics section is Products of Conception.
• Since this procedure is reported from the Obstetrics section, this means the procedure is reported on the mother’s record and not on the record of the newborn.
• There is no code table for the root operation Excision in the Obstetrics section, so for procedures to excise or remove masses from the lungs or airway the root operation is “Repair”. According to ICD-10-PCS: An Applied Approach, “The Repair root operation is the Not Elsewhere Classified (NEC) value for the ICD-10-PCS root operations, meaning that the procedure cannot be classified elsewhere in the system.” Since the Obstetrics section does not include the root operation to classify a procedure as an Excision, the root operation Repair is used as the default.

For the root operation Repair in the Obstetrics section, the qualifier value indicates the fetal body system that was operated on, which in these cases will be the respiratory system.

Note that this direction from Coding Clinic relates to a single, specific case. The documentation for each individual operative report will need to be reviewed carefully and compared with this and other official advice and coding guidelines to determine the correct root operation, approach, device and qualifier value for a given case with certainty.

Coding Scenario

Below is a good example of the documentation you would expect to see in an operative report for an ex utero intrapartum (EXIT) procedure. Note that there are separate operative notes for the procedures performed on the mother and the procedures performed on the fetus. However, as indicated above, only a single ICD-10-PCS code is assigned for the EXIT procedure and it is reported on the mother’s record.

Cesarean Operative Note

Preoperative Diagnosis: C-Section Indications: Fetal Anomaly
Postoperative Diagnosis: C-Section Indications: Fetal Anomaly
Procedure: EXIT to *CPAM resection with bilateral salpingectomy
* CPAM stands for congenital pulmonary airway malformation

Indication for Procedure:

31 y.o. G3P3003 at 38w2d weeks gestation undergoing cesarean delivery for EXIT procedure with bilateral salpingectomy due to fetal CPAM.

The patient was counseled regarding the risks of this operation, including bleeding, infection, injury to the bladder or bowel or other organs, and the possible need for blood transfusion or hysterectomy.

The uterus was exteriorized and the placenta was mapped using ultrasound guidance was noted to be anterior and maternal left. Decision was made for a fundal uterine incision extending posteriorly. An external cephalic version was done to allow the fetus to be repositioned into breech presentation to better facilitate fetal chest exposure. A hysterotomy was made by the fetal surgery team using hemostatic sutures and staples. The fetal head and chest were brought through the hysterotomy with the lower body remaining en utero. Amnio infusion was started. Please see *fetal surgery note for details of fetal CPAM resection. *This note follows below

At the completion of the fetal CPAM resection, the lower portion of the fetus was delivered through the hysterotomy. The cord was clamped and cut and the neonate was handed to the awaiting neonatology team. The placenta was delivered with gentle cord traction. The hysterotomy sutures and staples were noted to be entrapping a portion of membranes and were excised. The hysterotomy was closed with 2 layers of v-lock suture. A third layer of Monocryl suture was used in close the serosa in a baseball fashion. Coseal was placed of the hysterotomy for hemostatsis and adhesion barrier.

Fetal Surgery Note:

With the fetus partially delivered from the hysterotomy and in the right lateral decubitus position, a left 5th intercostal space posterolateral thoracotomy was created. The left chest was entered and the large lung lesion encountered. The lesion was delivered with some difficulty and was noted to replace the entire left upper lobe. The decision was made to proceed with removal of the lobe.

The pulmonary arterial supply was individually controlled, ligated and divided with a combination of CoolSeal cautery and suture ligation. The branches of the superior pulmonary vein were ligated and divided between absorbable ligatures. The incomplete fissure was divided with the CoolSeal. The left upper lobe bronchus was controlled with a large hemoclip and divided distally. The specimen was handed off from the field for further histologic evaluation. A 10-French thoracostomy tube was passed through a skin incision and positioned in the posterior apex. It was secured using 5-0 Prolene to the skin. Meticulous hemostasis was ensured and attention was then turned towards closure.The wounds were closed in layers of absorbable sutures. Steri-Strips and sterile dressings were applied.

Once the repair was completed, we delivered the fetus entirely. With gentle ventilation, the fetal pulse-ox was noted to rise to >90%. The cord was clamped and divided. Dr. then carried the newborn to the resuscitation room and placed him on the warming bed in the care of the NICU resuscitation team. The attention was then tuned toward closure of the uterus and abdomen.

ICD-10-PCS Code

For this coding scenario, assign 10Q00ZK Repair respiratory system in products of conception, open approach for the resection of the fetus’ left upper lung lobe. A code for the cesarean section would be also assigned.

Resources

• ICD-10-PCS
• AHA Coding Clinic
• ICD-10-PCS: An Applied Approach

Frequently Asked Questions

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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.