A patient presents for robotic-assisted laparoscopic radical prostatectomy. During the procedure partial removal of the bilateral vas deferens was accomplished and the bilateral seminal vesicles were removed. Does a radical prostatectomy include resection of the vas deferens and seminal vesicles or should these procedures be coded separately? What are the appropriate code assignments for robotic-assisted laparoscopic radical prostatectomy?
Radical procedures can have different meanings depending on the procedure, and the term “radical” is not always reliable information for coding the procedure. The coder should instead be guided by the information in the operative report. In ICD-10-PCS, code separately the organs or structures that were actually removed and for which there is a distinctly defined body part. The ICD-10-PCS guideline B3.2a states if during the same operative session the same root operation is repeated at different body sites that are defined by distinct values of the body part character, multiple procedures should be coded.
The robotic assistance may be coded if desired. For this case, based on the documentation in the submitted operative report, assign ICD-10-PCS codes as follows:
0VT04ZZ Resection of prostate, percutaneous endoscopic approach, for the resection of the prostate
0VT34ZZ Resection of bilateral seminal vesicles, percutaneous endoscopic approach, for the resection of the bilateral seminal vesicles
0VBQ4ZZ Excision of bilateral vas deferens, percutaneous endoscopic approach, for the partial removal of the bilateral vas deferens
8E0W4CZ Robotic assisted procedure of trunk region, percutaneous endoscopic approach
This advice is specific to this case and should not be interpreted that all radical prostatectomies have these component procedures done.