Question

66. This patient was admitted with a large pelvic mass and underwent an e tory laparotomy. Pathology confirmed carcinoma of the left ovary metastasis to the omentum. A total greater omentectomy, excision of left ovarian and radical abdominal hysterectomy were performed, which in this case removal of the uterus and upper vagina. Bilateral salpingo-oophorectomy performed. What codes are assigned? ICD-10-CM Code(s) with POA Indicator and MS-DRG: ICD-10-PCS Code(s): with extensive was also

Answer 1

ICD-10-CM: C56.2-Y, C78.6-Y

MS-DRG: 737
Rationale for these code is as follows:
For code C56.2, the Table of Neoplasms main term is ovary, column, malignant primary.
For code C78.6, the Table of Neoplasms main term is omentum, column, malignant secondary.
ICD-10-PCS: 0DTS0ZZ, 0UT90ZZ, 0UTC0ZZ, 0UBG0ZZ, 0UT20ZZ, 0UT70ZZ
Rationale: For code 0DTS0ZZ, the Alphabetic Index main term is Resection, subterms omentum, greater. For code 0UT90ZZ, the Alphabetic Index main term is Resection, subterm uterus. For code 0UTC0ZZ, the Alphabetic Index main term is Resection, subterm cervix. For code 0UBG0ZZ, only some vaginal part was removed so the root operation is Excision. For code 0UT20ZZ, the Alphabetic Index main term is Resection, subterms ovary, bilateral. For code 0UT70ZZ, the Alphabetic Index main term is Resection, subterm fallopian tubes, bilateral. Refer to Coding Guideline B3.2a regarding assignment of multiple procedure codes (CMS 2017b).