The Whipple procedure, also known as a pancreaticoduodenectomy, is a multipart surgery performed as a treatment primarily for people affected by pancreatic cancer. It may also be performed to treat tumors, cysts and other disorders of the pancreas, bile duct and/or the duodenum, such as pancreatitis, ampullary cancer, bile duct cancer, neuroendocrine tumors and/or trauma to the pancreas or small intestine.
The intent of the Whipple procedure is to remove the head of the pancreas, which is where most tumors occur, and therefore, prevent the tumor from growing and spreading to other organs. However, because the pancreas is so integrated with other organs, the surgeon must also remove the duodenum, gallbladder, a portion of the common bile duct and sometimes a portion of the stomach. At the completion of the procedure, the surgeon must reconnect the remaining organs to allow for normal digestive function after surgery.
There are two general types of Whipple procedures: the conventional Whipple (pancreaticoduodenectomy) and the pylorus sparing Whipple. In a conventional Whipple, typically the head of the pancreas, entire duodenum, gallbladder, and a portion of the stomach and common bile duct are removed. What primarily differentiates the pylorus sparing Whipple from the standard Whipple procedure is that the pylorus is preserved, and no part of the stomach is removed. The preservation of the stomach and proximal duodenum sustains the function of the gastric reservoir, allowing more normal gastric emptying. In both procedures, the digestive tract is reconstructed with the remaining organs.
Although there is no difference between the two procedures in terms of long term survival rates, the main advantages of the pylorus sparing Whipple procedure is the likelihood of better nutritional status postoperatively, and the procedure involves a slightly less complicated surgical reconstruction.
Whipple procedures may be performed via an open approach, laparoscopically and with or without robotic assistance. An open surgical approach is the approach more commonly used. The laparoscopic and robotic techniques are both minimally invasive, but these procedures may require extended operative time. In some cases, a procedure is initially started using a minimally invasive approach but complications or technical difficulties may require an open approach in order to complete the surgery.
A common postoperative complication is leaking of pancreatic fluid from the pancreatic remnant. If this occurs, a drain may be inserted through the skin to allow drainage. Weight loss may occur following the Whipple procedure, because fewer pancreatic enzymes that assist in digestion are produced after surgery.
Although there are multiple variations of the Whipple procedure, the procedure performed will be dependent on the patient’s diagnoses. Therefore, when reporting codes for Whipple procedures, code assignment is based on what was done.
Since the objective of a Whipple is to remove any involved body parts, the appropriate root operations are “Excision” to capture the partial removal of the pancreas and other body parts and/or “Resection” for the complete removal of the pancreas and other body parts. A separate ICD-10-PCS code should be assigned for each body part that is excised or resected.
Although at the end of these procedures the routes of normal passage may be altered, that is not the objective of a Whipple procedure, and therefore, “Bypass” is not the appropriate root operation. Whipple procedures require that the remaining organs be reconnected, therefore, the anastomosis is inherent to the total surgery and not coded separately.
The following examples are provided to assist coding professionals when assigning codes for Whipple surgery. Refer to Coding Clinic Third Quarter 2014, pages 32-33, for previously published advice about the pyloric-sparing Whipple procedure.
A 64-year-old female, who was diagnosed with ampullary adenoma, presents for open standard Whipple procedure. Due to the malignant behavior of this tumor, a diagnostic laparoscopy was performed first and no evidence of further disease was found. After removal of the laparoscope, the patient’s abdomen was opened by extending the incision from the xiphoid down to below the umbilicus. The jejunum was divided about 15 cm distal to the ligament of Treitz.
Attention was then turned to the biliary dissection and the gallbladder was mobilized, removed and passed off for permanent specimen. The bile duct was encircled at the mid bile duct near the junction and then divided as there were no palpable vessels to the right side of it. The pancreatic neck was then transected and the stomach was excised. The duodenum was found to be redundant. A large palpable mass at the medial aspect of the duodenum was consistent with aggressive ampullary tumor, and therefore, the entire duodenum was removed. Standard closure and anastomoses were performed throughout the procedure. How should this Whipple procedure be coded?
Code assignment for the Whipple procedure is based upon physician documentation of the procedures performed. According to the operative report, a diagnostic laparoscopy was performed, the duodenum and gallbladder were resected and excisions were made of the stomach, pancreas and common bile duct and jejunum. Therefore, assign the following codes:
The anastomoses performed are considered inherent to the surgery, and are not coded separately.
A 77-year-old female presents due to carcinoma of the head of pancreas. The patient had a previous history of cholecystectomy twenty years ago. During surgery, the provider noted that the tumor was not near the proximal duodenum, and a pyloric sparing pancreaticoduodenectomy was performed, which included excision of the pancreas, duodenum and common bile duct, along with a pancreaticojejunostomy, and a hepaticojejunostomy. What are the appropriate ICD-10-PCS procedure code assignments for the Whipple pyloric sparing pancreaticoduodenectomy procedure?
Assign the following codes for the procedures performed:
In this case, the gallbladder had already been removed; the stomach was not excised; and the duodenum was not completely removed.
A 65-year-old female, who had previously undergone laparoscopic cholecystectomy and diagnosed with ampullary adenocarcinoma, presented for a Whipple procedure. During surgery, a midline abdominal incision was done, the head of the pancreas, a portion of the stomach and a portion of the common bile duct were excised along with complete removal of the ampulla of Vater and duodenum. Periaortic, retroperitoneal, common hepatic, and periportal lymph nodes were excised. A gastrojejunostomy, pancreaticojejunostomy and choledochojejunostomy were performed to connect the remaining stomach, pancreas and common bile duct to the jejunum. How should these procedures be coded?
Code assignment for the Whipple procedure is based upon physician documentation of the procedures performed. In this case, the duodenum was resected and the stomach, pancreas, common bile duct and lymph nodes were excised.
The remaining stomach, bile duct and pancreas are reconnected to the digestive tract and the anastomoses are not coded separately.
A patient with neuroendocrine carcinoma of the pancreas was admitted for surgery. After removal of the central pancreas, the decision was made to perform a pancreaticogastrostomy. The neck of the pancreas and the anterior pancreatic body were imbricated to the posterior wall of the stomach. The ligamentum teres and an omental flap were used to reinforce the pancreaticogastrostomy. What is the code assignment for the pancreaticogastrostomy and are additional codes assigned for the ligamentum teres and omental flap grafts?
Anastomosis of the pancreas to the stomach using local tissue to reinforce the anastomosis is included in the pancreas excision, and not coded separately. Assign the following ICD-10-PCS code:
0FBG0ZZ Excision of pancreas, open approach