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Coding for Hysterectomy

Author: Preview Account Views: 4407 Created: 2010-11-02 07:24 Last Updated: 2010-11-02 07:24

We have a case of a 51 year old female which presented to us with a primary diagnosis N85.1 (Endometrial adenomatous Hyperplasia) and secondary diagnoses of:
* N95.0
* D26.1

The medical team decided that an abdominal hysterectomy should be performed removing:
* Uterus
* Cervix
* Ovaries
* Fallopian tubes

When coding for procedures we have come up with two possibilities:
* 68.49 (Total Hysterectomy)
* 68.69 (Radical Hystrectomy)

When grouping the above using the radical hysterectomy, the grouper produces a DRG which is 'unrelated to the principal diagnosis'. However it works when using the Total Hysterectomy, but this procedure does not reflect the actual procedure performed, as not only the cervix was removed (definition of a total hysterectomy).

Please advise on how best to tackle the above issue. 

HIO Team answers:

A radical hysterectomy is a procedure usually performed in patients with malignant tumours. When the primary diagnosis is a tumour of the female genital system, a case with the procedure code 68.69 (radical hysterectomy) would be assigned to DRGs N02 or N03 ("uterine procedures for ... malignancy"). For this procedure, the primary diagnosis N85.1 (endometrial adenomatous hyperplasia) is considered unusual by the CY-DRG grouper resulting in the assignment of the DRG 901 ("extensive OR procedure without direct connection to principal diagnosis").

Please check whether the operation performed in this case is correctly coded with the code 68.69. If so, use the correct code, even if an unexpected DRG is generated. The case constellation you described has been forwarded to the InEK and can therefore be taken into consideration in the further development of the CY-DRG system. Thank you for your inquiry.