AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2020 Issue 4; Frequently Asked Questions

Robotic-Assisted Sigmoid Colectomy with Extension of Incision for Specimen Removal

This patient was found to have a large tubulovillous adenoma with focal high-grade dysplasia and presented for a laparoscopic robotic-assisted sigmoid colectomy with primary anastomosis. The procedure was started with an Optiview trocar technique to the right of the umbilicus. The abdomen was insufflated and the camera was introduced. The Da Vinci robot was brought to the table where it was docked into port in the usual fashion. Once the colon was completely mobilized, a linear endoscopic stapling device was then used to divide the colon at this point. The stapling port site at the umbilicus was extended slightly so that the specimen could be removed. The wound protector device was placed and the specimen was removed through the port without difficulty. The stapled end of the descending colon was then brought up through the wound protector device at skin level where it was prepared for anastomosis. A purse-string suture was placed above the staple line and the staple line amputated sharply with scissors. The descending colon was serially dilated to approximately 30 mm. The stapler was placed within the lumen and secured with a purse-string and placed back within the abdominal cavity. This port site incision was then closed. What is the appropriate ICD-10-PCS approach value when the colon was divided using a percutaneous endoscopic approach, however an incision was made to remove the specimen from the patient’s body and complete the anastomosis? ...

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