A patient with prostate cancer presents for a robotic-assisted laparoscopic prostatectomy. Pneumoperitoneum was established and the abdomen was insufflated. The robotic trocars were then placed in the standard configuration, and the robot was docked. The dissection was carried bluntly around to the anterior prostate and bladder neck. The bladder neck was divided sharply. The apex of the prostate was freed sharply and the urethra divided. The robot was then undocked. All laparoscopic ports were removed under direct vision. The midline incision was lengthened to allow extraction of the specimen. What is the appropriate ICD-10-PCS approach value when the prostate was detached from surrounding structures using a percutaneous endoscopic approach, however an incision was made to remove the specimen from the patient’s body?
Assign the approach value “4, percutaneous endoscopic” for the robotic-assisted laparoscopic prostatectomy. In this case, surgery was performed laparoscopically; at the end of the procedure, the midline incision was extended to assist in removing the specimen (prostate). According to the new ICD-10-PCS guideline B5.2b, “Procedures performed using the percutaneous endoscopic approach, with incision or extension of an incision to assist in the removal of all or a portion of a body part or to anastomose a tubular body part to complete the procedure, are coded to the approach value Percutaneous Endoscopic.”
An important factor in assigning the correct approach value in ICD-10-PCS is to determine what structures were detached and how they were detached based on the medical record documentation. The focus should be on the surgical technique or approach used for the detachment of those structures. Code assignment should not be based on the location or approach of where the structures were physically removed from the patient’s body.