AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2013 Issue 3; Ask the Editor
Total Hysterectomy
How is a total hysterectomy performed via an open approach coded? Is it appropriate to assign ICD-10-PCS codes for both the resection of the uterus and the cervix, when only a total hysterectomy is documented in the operative report? ...
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Article Overview
This article explains how a documented total hysterectomy is reflected in ICD-10-PCS coding and addresses whether related procedure codes should be reported when the operative report describes only the total procedure. It is intended for coding professionals working with surgical documentation and PCS assignment guidance.
Why This Topic Matters
Accurate procedure coding depends on understanding how a documented surgical term maps to the underlying anatomy and the relevant ICD-10-PCS framework. This topic is especially relevant for coders and auditors reviewing hysterectomy documentation.
What You Will Learn
- How an open total hysterectomy is addressed in ICD-10-PCS coding guidance.
- How the article frames the relationship between the documented procedure and PCS assignment.
- What source guidance is referenced for supporting the coding approach.
- How to interpret the article’s focus on uterine and cervical procedure coding at a high level.
Who Should Read This
- Inpatient coders
- Coding auditors
- HIM professionals
- CDI specialists
Codes Discussed
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