AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2015 Issue 1; Ask the Editor
Robotic-Assisted Laparoscopic Hysterectomy Converted to Open Procedure
A patient diagnosed with endometrial carcinoma underwent attempted robotic-assisted laparoscopic hysterectomy, converted to an open total abdominal hysterectomy and bilateral salpingo-oophorectemy. The robotic device was attached to the cervix and an attempt was made to mobilize the uterus. However, it was not possible to safely visualize the left uterine vessels; therefore, the robotic device was undocked and surgery was converted to an open procedure. What is the appropriate code assignment for attempted robotic-assisted laparoscopic hysterectomy, converted to an open total abdominal hysterectomy? ...
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Article Overview
This article discusses coding for a hysterectomy case in which a minimally invasive robotic-assisted approach was attempted and then converted to an open abdominal procedure. It is aimed at medical coders, auditors, and revenue cycle professionals who need to understand how the case is represented in ICD-10-PCS and how the article frames the reporting of the operative steps. The content focuses on general coding guidance, approach selection, and documentation implications for converted surgery cases.
Why This Topic Matters
Converted procedures can affect how operative steps are represented in inpatient procedural coding, so understanding the article helps coders interpret documentation consistently and avoid mismatches between intended and completed approaches.
What You Will Learn
- How converted robotic-assisted laparoscopic surgery is discussed in procedural coding terms
- How hysterectomy-related operative steps are represented at a high level
- How ICD-10-PCS guidance applies to attempted procedures that are converted to another approach
- How documentation of the operative sequence can affect coding review
Who Should Read This
- Medical coders
- Coding auditors
- Revenue cycle staff
- Clinical documentation improvement staff
- Health information management professionals
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