by Bonnie Schreck
February 8th, 2016
When reading through documentation in an operative report for a hysterectomy, for the ‘Procedure Performed’, a ‘TAH-BSO, and Omenectomy’ is performed. As with all operative reports, there are guidelines that should be followed when determining the appropriate ICD-10-PCS codes.
The first is identifying ‘TAH-BSO’. These are common abbreviations that are used in these types of procedures, which are defined as a ‘total abdominal hysterectomy with bilateral salpingo-oophorectomy’. Many facilities have a policy for abbreviations, that is, it needs to be on a facility-approved abbreviation list in order for the coding professional to be able to use that procedure when coding. If it is not an approved abbreviation, and if it is not documented anywhere else in the medical record, the provider should be queried to clarify the abbreviation.
When coding for the TAH-BSO, the entire uterus is removed, along with the right and left fallopian tubes and the right and left ovaries. These would be listed in the Female Reproductive System section, under the root word ‘Resection’. Because there are bilateral codes for the fallopian tubes and ovaries, three codes would be listed for these procedures (see codes at the end of the article). Also, because this is through the abdomen, the approach will be ‘Open’.
During many hysterectomies, although not listed in the ‘Procedures Performed’, the cervix or part of the cervix may be removed. When reading through the operative report, whether the cervix is partially excised or completely removed will determine ICD-10-PCS code selection. If partially excised, review the codes in the Female Reproductive System, under the root word ‘Excision’; if the cervix is completely removed, it would be a ‘Resection’.
For the omenectomy, the omentum is listed in the Gastrointestinal System section of PCS. This seems to be the most problematic of the procedures as much of the documentation seen is unclear. Documentation needs to state whether the greater omentum or the lesser omentum was operated on and if the procedure performed was an ‘Excision’ or ‘Resection’. If not stated, the provider will need to be queried for clarification.
The ICD-10-PCS coding for the TAH-BSO with Omenectomy would be: