A patient with a history of stress urinary incontinence presents for pubovaginal sling placement. What is the appropriate ICD-10-PCS code for this procedure? Specifically, we are not sure what the appropriate approach value would be for this procedure.
For the pubovaginal sling placement, assign the following ICD-10-PCS procedure code:
0TSD0ZZ Reposition urethra, open approach
The purpose of the procedure is to reposition the angle of the urethra so that it is not hypermobile, and the goal is to move the urethra into proper position. Structurally the sling is holding the urethra in place, and changing the angle so that it does not leak. The urethra is not deficient; it’s in the wrong place. The tape helps to keep it in the correct position, but is not performing the function of the urethra. Therefore, “Reposition” is the appropriate root operation.
Reposition is defined as putting in or putting back or moving some or all of a body part to its normal or other suitable location. Additionally, the approach is open, because the operative report states that flaps were raised on either side of the groin through two small incisions in order to perform the procedure. This means that the site of the procedure was exposed to direct visualization and therefore the approach is open.