FAQs: Surgical Site Procedure Codes

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ICD-10-PCS code characters

Q1: When entering the following code OUT90ZZ, the application gives an error?ICD-10 codes do not include the letters **O **(oh) or I (eye) as these are easily mistaken for the numbers 0 (zero) and 1 (one).  ICD-10 code OUT90ZZ should be entered as 0UT90ZZ and 0X6I0ZZ should be entered as 0X610ZZ.

List of Operative Procedure Codes

Q2: Where is the most current ICD-10-PCS and CPT operative procedure codes found?The current lists of operative procedure codes are found on the NHSN Surgical Site Infection (SSI) Events webpage in the Operative Procedure Code Documents section.

Procedure code documents for the past two years can be found on the NHSN Data Validation webpage.

NHSN Procedure Code Documents

Q3: How should facility medical coders use the NHSN procedure code documents for classifying surgical procedures for patient charges?The NHSN operative procedure code documents, posted on the NHSN site, are not intended to be instructive to medical coders for assigning procedure codes to surgical procedures.  The documents are **provided as a tool **to assist NHSN users participating in SSI reporting with categorizing operative procedures by NHSN procedure categories and to **standardize the reporting of surgical procedures **between facilities.

Updates to Procedure Codes

Q4: When are codes updated and how are users notified of updates?NHSN operative procedure codes are reviewed and updated annually and as needed.

Communication regarding updates to the operative procedure codes may be sent via email to individuals and vendors enrolled in NHSN or via NHSN newsletter communications.  The communication will contain specific details about the updates; therefore, it is critical that all NHSN users review their NHSN user contact information on a regular basis and update as necessary.

Using Procedure Codes

Q5: Are ICD-10-PCS or CPT procedure codes required to enter SSI events into NHSN?The use of the NHSN operative procedure codes (ICD-10-PCS and/ CPT) is required to determine the correct NHSN operative procedure category but entering the operative procedure code into the NHSN application remains optional.

Q6: I’m not sure if an operative procedure was correctly coded. What do I do ?NHSN operative procedure reporting is based on the operative procedure code(s) assigned by a trained medical coder. There are several instructions, guidelines and conventions that govern how and when medical codes are assigned. For questions related to correct procedure code assignment consult with your facility medical coder.

Scope

Q7: A single trip to the operating room can generate multiple procedure codes, how should ‘Scope’ be entered into NHSN if open and scope codes are assigned to procedures in the same NHSN procedure category?Scope is reported based on the primary incision site. If an open and scope code is assigned to procedures in the same NHSN procedure category, then the procedure should be reported to NHSN as Scope = NO. The open designation is considered a higher risk procedure.

Q8: Using the ICD-10-PCS codes, is there a quick way to know when to select “Scope = YES”?ICD-10-PCS codes can be helpful in answering the scope question. The fifth character indicates the approach to reach the operative procedure site:

If the fifth character of the ICD-10-PCS procedure code is a four (4) or F, then the field for scope should be YES.

HYST

Q9: When reporting hysterectomy procedures to NHSN, what determines when a procedure is categorized as a vaginal hysterectomy verses an abdominal hysterectomy? Are there definitions for each of these procedures?A trained medical coder, using current medical coding guidelines and conventions, should assign the correct procedure code (CPT and ICD-10-PCS) to the hysterectomy procedure.

For the purpose of SSI reporting, the NHSN HYST – abdominal hysterectomy operative procedure category includes hysterectomy procedures/codes that involve an incision into the abdomen, including trocar insertion.

The hysterectomy procedure approach (5th character of the ICD-10 operative procedure code assigned by a medical coder) identifies whether an abdominal incision was made and determines if the procedure is categorized as a NHSN HYST or VHYS.

The definition of each NHSN operative procedure category is listed in the NHSN “ICD-10-PCS Procedure Code Mapping to NHSN Operative Procedure Codes” document.  This document can be found on the NHSN Surveillance for Surgical Site Infection (SSI) Events web page under “Operative Procedure Code Documents”.

CPT HYST Procedures

Q10: Why are there CPT codes that include “vaginal hysterectomy” in the procedure description included in the HYST-abdominal hysterectomy procedure category?Hysterectomy procedures / codes that involve an incision into the abdomen, including trocar insertion are categorized as NHSN HYST – abdominal hysterectomy procedures; therefore, a few of the CPT codes that include “laparoscopy, surgical, with vaginal hysterectomy” in the procedure description are included in the HYST procedure category.  The use of a laparoscopic approach indicates that an incision was made into the abdomen.

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