AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2017 Issue 1; Ask the Editor
Perineal Urethrostomy
A patient with squamous cell carcinoma of the glans penis had a total penectomy and perineal urethrostomy. During surgery, the urethra was dissected out at the shaft of the penis, then divided and dissected towards the perineum. The penis was divided and a spot was identified from the anus to the base of the scrotum as the place for the urethrostomy to be located. The perineal fat was dissected to this location, a V-shaped incision was made, and the urethra was brought through that opening. The V of the skin incision was attached to the urethra and the urethra was matured to the skin. A catheter was inserted on this end and left indwelling, and the balloon was inflated. A drain was inserted into the space where the urethra and the base of the penis was located and brought out through a separate stab incision and secured to the skin, then the scrotum was also brought more cephalad. What is the correct root operation and body part for the perineal urethrostomy? ...
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Article Overview
This coding article presents a surgical scenario centered on creation of a perineal urethrostomy in the setting of total penectomy for malignancy. It is aimed at inpatient coders and coding educators who work with ICD-10-PCS and need to understand how to classify the procedure by root operation and body part in a surgical case narrative.
Why This Topic Matters
Accurate ICD-10-PCS assignment for urethral diversion and related genital surgery depends on correctly interpreting operative anatomy and the intent of the procedure. This article helps readers assess how a complex operative note should be translated into PCS coding concepts.
What You Will Learn
- How a perineal urethrostomy is described in operative language
- How the scenario relates to ICD-10-PCS classification
- How to think about the procedure in the context of concurrent genital surgery
- How inpatient coding questions may be framed around root operation and body part selection
Who Should Read This
- Inpatient medical coders
- Coding educators
- Coding auditors
- Clinical documentation specialists
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