ICD-9 to ICD-10 PCS -- Robotic Assisted Procedures - Where do we go from here??

The conversion date for ICD-10CM and PCS has now been confirmed by CMS to be October 1,
2014. The challenge for coders is to continue their education and proficiency in the new ICD-10 pcs system. The onus to become proficient in this new coding code-set system begins in earnest. Not only do coders need to understand the new ICD-10 pcs system and its guidelines, but they need a very clear understanding of the devices, anatomy and physiology too.

Robotic Assist at surgery has traditionally been coded in ICD-9 volume 3, with the following category:

17.4 Robotic-Assisted Procedures
17.41 Open robotic assisted procedure
17.42 Laparoscopic-assisted robotic procedure
17.43 Percutaneous robotic assisted procedure
17.44 Endoscopic robotic assisted procedure
17.45 Thoracoscopic robotic procedure
17.49 Other and unspecified robotic assisted procedure

Usage of a robotic assistance or computer assisted surgical system, laparoscopic surgeons gain a skilled technical advantage that includes enhanced vision of the operative field from the scope, and improved manual dexterity for fine motor procedures such as lysis of adhesions, within the abdominal cavity. In addition, the surgical robotic assist device allows a physician increased ability for surgical precision of incision, excision, reattachment and opening/closing of the surgical operative field. However, the usage of the robotic assistive device, does not mean the primary surgical procedure itself has changed. The basic concept of the surgery is still defined as a laparoscopic procedure.

According to CMS and the usage of HIPPA defined code-sets, facilities are required to report the primary surgical procedure with the appropriate ICD-9-CM Volume 3 procedure, plus the appropriate procedure code for the robotic assistance. (e.g. 68.41 and 17.42). The HCPCS procedure code-set gives us only the code “S2900”, (surgical techniques requiring use of robotic surgical system),which may be used with the CPT4 procedure coding for physician based service claims.

An area of concern for coding of the utilization of surgical robotic assist devices for third party payers/Insurance carriers is those payers are not governed under federal CMS guideline. (payers such as Blue Cross, Blue Shield, Aetna, etc…) These private payers may provide their own policy coverage and guidelines for specific procedures that utilize a robotic assist device. When submitting claims to private or 3rd party payers, you will want to know up front if they want the S2900 HCPCS code appended to the claim in addition to the ICD-10PCS code. Currently, there is no clear information regarding how these 3rd party payers will respond in regard to ICD-10pcs and claim submission. As we get closer to the go-live date for ICD-10PCS on October 1, 2014, the claim submission issues will be a hot-topic that will need clarification from these 3rd party privare insurance payers.

As the coding industry progresses toward transition of ICD-10PCS, this new procedural coding
system enables us to give a more accurate picture of what was actually performed with the robotic assist devices. What would have previously been coded in ICD-9 volume 3, as a laparoscopic total abdominal hysterectomy (LAH) as code 68.41, can now be coded as 0UB94ZZ, or as 0UT94ZZ as per the ICD-10PCS tables (found at http://www.cms.gov/Medicare/Coding/ICD10/2013-ICD-10-PCS-GEMs.html)

The correct choice of code in ICD-10PCS will depend on what is documented and noted in the
operative report. In the illustrations below, the ICD-10PCS tables outline two different ICD-10 PCS procedure code scenarios that could be considered with usage of the laparoscopic robotic device.

Lets review and consider code 0UB94ZZ from the ICD-10 code-set:
0UB94ZZ Or code: 0UT94ZZ

The difference between these two codes 0UB94ZZ, and 0UT94ZZ is that code OUT94ZZ is a
Resection: Cutting out or off, without replacement, all of a body part whereas code OUB94ZZ is a Excision: Cutting out or off, without replacement, a portion of a body part

It is these verbiage differences (eg,“resection vs/excision”) where ICD-10PCS differentiates between the procedures in the code-set. These differences need to be documented clearly within the operative record by the physician or provider. This becomes a critical informational area for the coders to know and understand what the physician has documented in the operative report. In addition, the application of an incorrect procedure could impact the DRG weight for those specific services to the revenue for the hospital or facility either up or down. In addition, the coder must truly understand the ICD-10PCS guidelines and terminology as to what procedure was performed, and how the procedure was performed to correctly code the ”operation”, “body part”, and “approach” in ICD-10pcs guidelines. The fact that the procedure was performed with a robotic assist also becomes very important at this point.

However, it is interesting to note, that ICD-10PCS does not specifically state a “robotic” assist at all, nor does it address a “laparoscopic” assist with the new ICD-10 PCS codes. ICD-10 PCS simply gives us the choices of “Open”, “Percutaneous”, “Percutaneous Endoscopic” “Via Natural or Artificial Opening” or “Via Natural or Artificial Opening Endoscopic” as the surgical/procedure approach choices. CMS addresses the definition of “percutaneous endoscopic” as: Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure…

In using the above guideline and definition from CMS, the best definition for a hysterectomy utilizing a laparoscopic robotic device would be the percutaneous endoscopic definition.

Below is an operative record excerpt for a Robotic-Assisted Laparoscopic Hysterectomy (RALH)

OPERATIVE REPORT: Total laparoscopic hysterectomy using the daVinci robotic equipment.

The abdomen and vagina were prepped and draped in the normal sterile fashion. A Foley catheter was inserted. A long weighted speculum was placed into the vagina and an anterior wall retractor was placed into the vagina. The cervix was grasped with a single-tooth tenaculum and the uterus was sounded to 7.5 cm and was anterior.

The balloon manipulator was then properly placed. The balloon was filled to approximately 3 cc of saline. The cervical cup was placed around the cervix. A sterile glove filled with a lap pad was then placed inside the vagina to help with pneumoperitoneum. An 11 mm port was placed in the left upper quadrant just under the inferior costal margin. Adequate pneumoperitoneum was obtained. A 12 mm port was placed supraumbilically and the 12 mm trocar was placed through that port. The daVinci camera was then placed supraumbilically. 3 more ports were then placed. The 11 mm port was then placed in the left upper quadrant and there were two 8 mm ports that were placed 10 cm laterally to the umbilicus and 2 cm inferiorly. The daVinci robot was then docked in the normal fashion. The patient was placed in steep Trendelenburg positioning.

Inspection of the pelvis showed a normal uterus, ovaries and tubes. The right fallopian tube was cauterized using the PK bipolar cautery and was ligated using the hot shears. The utero-ovarian ligament was also coagulated and cut. The round ligament was coagulated and cut. A bladder flap was created with the hot shears and the bladder was dissected down from the cervix.

This entire procedure was then repeated on the left side. The blue balloon cuff was then identified and an incision was made in the cervicovaginal junction on top of the vaginal cuff. This was also repeated posteriorly. The incision was extended laterally, freeing the uterus from the surrounding vagina and including the excision of the cervix itself.

The uterus was then morcellated and delivered posteriorly through the endocatch bag using the robotic assistant. The vaginal cuff was closed with four figure-of-eight sutures of 0 Vicryl. The ureters were identified bilaterally. The entire pelvis was hemostatic. The supraumbilical site was closed with a suture of 0 Vicryl. The skin was closed with 4- 0 Monocryl using subcuticular stitches. Steri-Strips were placed. The final needle, sponge and instrument count
was correct. The patient tolerated the procedure well. Patient to the recovery room in good condition.

If we code this operative record excerpt, per our ICD-10pcs coding guidelines, the procedure above would be coded as the ICD-10PCS code 0UB94ZZ. The rationale for this code choice, is the operative note states the uterus was removed, but not the fallopian tubes or ovaries. If you review the anatomy and physiology of the uterus, fallopian tubes and ovary(ies), those body parts are all connected as one major “organ” with accessory structures. As per the definition of a percutaneous endoscopic procedure, this approach would be chosen, (as the surgeon utilized a laparoscopic surgical assist device , aka daVinci robot, for the approach). There was no other device or qualifier noted in the record.

In conclusion, the surgical robotic assist device, will become inclusive into the entire ICD-10pcs
process(es) as part of the approach, rather than a separately identifiable assistive device, as is the case with ICD-9 procedural coding.

Again...  the full ICD-10 cm and ICD-10 pcs codes in addition to all draft coding guidelines for ICD-10 can be found at www.cms.gov.

Happy Coding!