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<!DOCTYPE html> <html lang="en-us" class="cdc-2022 theme-teal cdc-page-type-content cdc-tp5" > <head> <meta charset="utf-8" /> <meta http-equiv="X-UA-Compatible" content="IE=Edge" /> <meta content="width=device-width, initial-scale=1, shrink-to-fit=no" name="viewport" /> <meta name="mobile-web-app-capable" content="yes" /> <meta name="apple-mobile-web-app-capable" content="yes" /> <meta name="theme-color" content="#075290"> <link rel="apple-touch-icon" sizes="180x180" href="/TemplatePackage/4.0/assets/imgs/favicon/apple-touch-icon.png"> <link rel="icon" type="image/png" sizes="32x32" href="/TemplatePackage/4.0/assets/imgs/favicon/favicon-32x32.png"> <link rel="icon" type="image/png" sizes="16x16" href="/TemplatePackage/4.0/assets/imgs/favicon/favicon-16x16.png"> <link rel="mask-icon" href="/TemplatePackage/4.0/assets/imgs/favicon/safari-pinned-tab.svg" color="#0056b3"> <meta name="msapplication-TileColor" content="#0056b3"> <meta name="theme-color" content="#0056b3"> <link rel="stylesheet prefetch" href="/TemplatePackage/contrib/libs/bootstrap/latest/css/bootstrap.min.css?_=79008" /> <link rel="stylesheet prefetch" href="/TemplatePackage/4.0/assets/css/app.tp5.min.css?_=79008" /> <link rel="stylesheet" media="print" href="/TemplatePackage/4.0/assets/css/print.min.css?_=79008" />  <script src="https://www.cdc.gov/JScript/metrics/topic_levels.js?_=79008"></script> <script src="https://www.cdc.gov/JScript/metrics/adobe/launch/b36c1852e229/2c674008a127/launch-04da70ea688d.min.js" async></script> <title>FAQs: Surgical Site Procedure Codes | NHSN | CDC</title> <meta name="description" content="CDC’s National Healthcare Safety Network is the nation’s most widely used healthcare-associated infection tracking system."/> <meta name="robots" content="index, archive" /> <meta property="cdc:template_version" content="4.0"/> <meta property="cdc:first_published" content="June 13, 2018"/> <meta property="cdc:last_updated" content="September 18, 2023"/> <meta property="cdc:last_reviewed" content="September 18, 2023"/> <meta property="cdc:content_source" content="CENTERS FOR DISEASE CONTROL AND PREVENTION; DIVISION OF HEALTHCARE QUALITY PROMOTION; NATL CTR FOR EMERGING & ZOONOTIC INFECTIOUS DISEASES"/> <meta property="cdc:maintained_by" content="DIVISION OF HEALTHCARE QUALITY PROMOTION; NATL CTR FOR EMERGING & ZOONOTIC INFECTIOUS DISEASES"/> <meta property="cdc:content_id" content="10941" /> <meta property="cdc:build" content="3426" /> <meta property="cdc:version" content="4.24.4" /> <meta property="cdc:page_type" content="cdc_page" /> <meta property="cdc:page_origin" content="wcms"/> <link rel="canonical" href="https://www.cdc.gov/nhsn/faqs/faq-ssi-proc-codes.html"/> <meta property="cdc:wcms_build" content="4.24.4 - b.3426" />  <meta name="DC.date" content="2023-09-18T03:59:17Z" /> <meta name="cdc:last_published" content="2024-05-13T14:51:45Z" /> <script type="application/ld+json"> { "@context": "https://schema.org", "@type": "FAQPage", "mainEntity": [ {"@type": "Question","name": "Q1: When entering the following code OUT90ZZ, the application gives an error?","acceptedAnswer": {"@type": "Answer","text": "ICD-10 codes do not include the letters <strong>O </strong>(oh) or <strong>I </strong>(eye) as these are easily mistaken for the numbers <strong>0 </strong>(zero) and <strong>1</strong> (one). ICD-10 code <strong>O</strong>UT90ZZ should be entered as <strong>0</strong>UT90ZZ and 0X6<strong>I</strong>0ZZ should be entered as 0X6<strong>1</strong>0ZZ."}},{"@type": "Question","name": "Q2: Where is the most current ICD-10-PCS and CPT operative procedure codes found?","acceptedAnswer": {"@type": "Answer","text": "</p> <ul class='list-false'> <li>The current lists of operative procedure codes are found on the <a href='/nhsn/acute-care-hospital/ssi/index.html'>NHSN Surgical Site Infection (SSI) Events web page</a>.</li> <li>Procedure code documents for the past two years can be found on the <a href='/nhsn/validation/index.html'>NHSN Data Validation’s web page</a>.</li> </ul> <p>"}},{"@type": "Question","name": "Q3: How should facility medical coders use the NHSN procedure code documents for classifying surgical procedures for patient charges?","acceptedAnswer": {"@type": "Answer","text": "The NHSN operative procedure code documents, posted on the NHSN site, are <strong>not intended to be instructive to medical coders for assigning procedure codes</strong> to surgical procedures. The documents are <strong>provided as a tool </strong>to assist NHSN users participating in SSI reporting with <strong>categorizing operative procedures</strong> by NHSN procedure categories and to <strong>standardize the reporting of surgical procedures </strong>between facilities."}},{"@type": "Question","name": "Q4: When are codes updated and how are users notified of updates?","acceptedAnswer": {"@type": "Answer","text": "NHSN operative procedure codes are reviewed and updated annually and as needed.</p> <p>Communication regarding updates to the operative procedure codes are sent via email to individuals and vendors enrolled in NHSN. The emails 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."}},{"@type": "Question","name": "Q5: Are ICD-10-PCS or CPT procedure codes required to enter SSI events into NHSN?","acceptedAnswer": {"@type": "Answer","text": "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.</p> <p> </p> <p>"}},{"@type": "Question","name": "Q6: I’m not sure if an operative procedure was correctly coded. What do I do ?","acceptedAnswer": {"@type": "Answer","text": "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.</p> <p> </p> <p>"}},{"@type": "Question","name": "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?","acceptedAnswer": {"@type": "Answer","text": "Scope is reported based on the primary incision site. If an <strong><em>open and scope</em></strong> code is assigned to procedures in the same NHSN procedure category, then the procedure should be reported to NHSN as <strong>Scope = NO</strong>. The <strong><em>open</em></strong> designation is considered a higher risk procedure."}},{"@type": "Question","name": "Q8: Using the ICD-10-PCS codes, is there a quick way to know when to select “Scope = YES”?","acceptedAnswer": {"@type": "Answer","text": "ICD-10-PCS codes can be helpful in answering the scope question. The fifth character indicates the approach to reach the operative procedure site:</p> <div class='table-responsive'> ICD-10-PCS code for fifth character indicates the approach <strong>ICD-10 5th Character</strong> <strong>Approach</strong> <strong>NHSN Scope Designation</strong> <strong>0</strong> Open NO <strong>3</strong> Percutaneous (Included only in CRAN and VSHN categories- procedures with BURR holes) NO <strong>4</strong> Percutaneous endoscopic YES <strong>7</strong> Via natural or artificial opening NO <strong>8</strong> Via natural or artificial opening with endoscopic NO <strong>F</strong> Via natural or artificial opening with percutaneous endoscopic assistance YES </div> <p> </p> <p>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."}},{"@type": "Question","name": "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?","acceptedAnswer": {"@type": "Answer","text": "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.</p> <p>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.</p> <p>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.</p> <p>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 <a href='/nhsn/acute-care-hospital/ssi/index.html'>NHSN Surveillance for Surgical Site Infection (SSI) Events web page</a> under “Operative Procedure Code Documents”."}},{"@type": "Question","name": "Q10: Why are there CPT codes that include “vaginal hysterectomy” in the procedure description included in the HYST-abdominal hysterectomy procedure category?","acceptedAnswer": {"@type": "Answer","text": "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 “<em>laparoscopy, surgical, with <strong>vaginal hysterectomy</strong></em>” 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.</p> <div class='table-responsive'> ICD-10-PCS code for fifth character indicates the approach <strong>Procedure Category</strong> <strong>Procedure Code</strong> <strong>Procedure Code Description</strong> <strong>HYST</strong> 58550 Laparoscopy, surgical, with <strong>vaginal hysterectomy</strong>, for uterus 250 g or less <strong>HYST</strong> 58552 Laparoscopy, surgical, with <strong>vaginal hysterectomy</strong>, for uterus 250 g or less; with removal of tubes(s) and /or ovary(s) <strong>HYST</strong> 58553 Laparoscopy, surgical, with <strong>vaginal hysterectomy</strong>, for uterus greater than 250 g <strong>HYST</strong> 58554 Laparoscopy, surgical, with <strong>vaginal hysterectomy</strong>, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) </div> <p>"}} ] } </script> </head> <body class="no-js cdc-page"> <div id="skipmenu"> <a class="skippy sr-only-focusable" href="#content">Skip directly to site content</a> <a class="skippy sr-only-focusable" href="#headerSearch">Skip directly to search</a> </div> <div class="header-language-bar container text-right pt-1 pb-1 fs0875"> <a href="/spanish/"><span lang="es-us">Español</span></a><span class="link-divider"> | </span> <a href="https://wwwn.cdc.gov/pubs/other-languages/">Other Languages</a> </div> <div class="cdc-header-official-notice container noindex"> <div class="cdc-header-official-notice-header d-flex"> <img src="/TemplatePackage/4.0/assets/imgs/uswds/us_flag_small.png" width="16" height="11" alt="U.S. flag" /> <small class="ml-2">An official website of the United States government <button class="cdc-header-official-notice-header-btn">Here's how you know <span class="cdc-header-official-notice-header-icon x12 fill-p cdc-icon-arrow-down"></span></button></small> </div> <div class="cdc-header-official-notice-body row" style="display: none;"> <figure class="col-lg-6 d-flex"> <img class="cdc-header-official-notice-body-img" src="/TemplatePackage/4.0/assets/imgs/uswds/icon-dot-gov.svg" alt="Official icon" aria-hidden="true" /> <figcaption class="cdc-header-official-notice-body-info ml-3"> <p class="cdc-header-official-notice-body-title mb-1"><strong>Official websites use .gov</strong></p> <p>A .gov website belongs to an official government organization in the United States.</p> </figcaption> </figure> <figure class="col-lg-6 d-flex"> <img class="cdc-header-official-notice-body-img" src="/TemplatePackage/4.0/assets/imgs/uswds/icon-https.svg" alt="Lock icon" aria-hidden="true" /> <figcaption class="cdc-header-official-notice-body-info ml-3"> <p class="cdc-header-official-notice-body-title mb-1"><strong>Secure .gov websites use HTTPS</strong></p> <p>A lock ( <span class="x16 fill-black cdc-icon-lock-alt-solid"></span> ) or https:// means you've safely connected to the .gov website. 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</div> </div> </div> <div class="container-fluid site-title"> <div class="container"> <div class="row"> <div class="col"> <div class="display-6 text-white fw-500 pt-1 pb-1 site-title-inner "> <a href="/nhsn/index.html"> National Healthcare Safety Network (NHSN)</a> </div> </div> </div> </div> </div> <nav role="navigation" aria-label="Mobile Nav" id="mobilenav" class="sticky-top"> </nav>  <div class="container-fluid feature-area"> <div class="container"></div> </div> </header> <div class="container d-flex flex-wrap body-wrapper bg-white"> <main class="col-lg-9 order-lg-2" role="main" aria-label="Main Content Area"> <div class="row visual-element"> <div class="col"> </div> </div> <div class="section-nav-area"> <nav role="navigation" aria-label="Section Nav" class="w-100 sticky-top"></nav> </div> <div class="row"> <div class="col content "><div class="syndicate"><h1 id="content" class="page-title">FAQs: Surgical Site Procedure Codes</h1></div> <div class="title-bar"> <a href="#print" class="print-link" aria-label="print this page" onclick="window.print()">Print</a> </div> <div class="mb-3 card tp-related-pages fourth-level-nav d-none"> <div class="card-header collapse-icon"> <a class="collapse-link float-right nav-minus fs0875" data-toggle="collapse" href="#collapse_1094166422901a9f1c" aria-expanded="false" aria-controls="collapse_1094166422901a9f1c"> <svg viewBox="0 0 24 24" focusable="false" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink"> <title>Minus</title> <path d="M19,13H5V11H19V13Z"></path> </svg> </a> <div class="h4">Related Pages</div> </div> <div class="card-body collapse show" id="collapse_1094166422901a9f1c"></div> </div> <div class="syndicate"> <div class="row "><div class="col-md-12"> <div class="card tp-on-this-page mb-3 d-block " data-sid=""> <div class="card-header">On This Page</div> <div class="card-body"> <ul class="block-list order-1 list-group list-group-flush"> <li class="list-group-item"><a href="#ICD-10-PCS-code-characters">ICD-10-PCS code characters</a></li><li class="list-group-item"><a href="#List-of-Operative-Procedure-Codes">List of Operative Procedure Codes</a></li><li class="list-group-item"><a href="#NHSN-Procedure-Code-Documents">NHSN Procedure Code Documents</a></li><li class="list-group-item"><a href="#Updates-to-Procedure-Codes">Updates to Procedure Codes</a></li><li class="list-group-item"><a href="#Using-Procedure-Codes">Using Procedure Codes</a></li><li class="list-group-item"><a href="#Scope">Scope</a></li><li class="list-group-item"><a href="#HYST">HYST</a></li><li class="list-group-item"><a href="#CPT-HYST-Procedures">CPT HYST Procedures</a></li> </ul> </div> </div> <p><a id="ICD-10-PCS-code-characters" title="ICD-10-PCS code characters" class="onThisPageAnchor"></a></p><h2>ICD-10-PCS code characters</h2><div id="faq-1843" class="cdc-faq accordion indicator-plus accordion-white mb-3 " role="tablist"><div class="card bar cdc-faq-item" id="faq-1843-1-question"><div class="card card-accordion "><button class="card-header collapsed " data-target="#faq-1843-1-answer" data-toggle="collapse" aria-expanded="false" role="tab" aria-controls="faq-1843-1-answer" data-controls="faq-1843-1-answer"><span class="card-title btn btn-link">Q1: When entering the following code OUT90ZZ, the application gives an error?</span></button><div class="collapse d-print-block " collapsed id="faq-1843-1-answer" role="tabpanel"><div class="card-body"><p>ICD-10 codes do not include the letters <strong>O </strong>(oh) or <strong>I </strong>(eye) as these are easily mistaken for the numbers <strong>0 </strong>(zero) and <strong>1</strong> (one).  ICD-10 code <strong>O</strong>UT90ZZ should be entered as <strong>0</strong>UT90ZZ and 0X6<strong>I</strong>0ZZ should be entered as 0X6<strong>1</strong>0ZZ.</p></div></div> </div></div></div><a id="List-of-Operative-Procedure-Codes" title="List of Operative Procedure Codes" class="onThisPageAnchor"></a><h2>List of Operative Procedure Codes</h2><div id="faq-9477" class="cdc-faq accordion indicator-plus accordion-white mb-3 " role="tablist"><div class="card bar cdc-faq-item" id="faq-9477-1-question"><div class="card card-accordion "><button class="card-header collapsed " data-target="#faq-9477-1-answer" data-toggle="collapse" aria-expanded="false" role="tab" aria-controls="faq-9477-1-answer" data-controls="faq-9477-1-answer"><span class="card-title btn btn-link">Q2: Where is the most current ICD-10-PCS and CPT operative procedure codes found?</span></button><div class="collapse d-print-block " collapsed id="faq-9477-1-answer" role="tabpanel"><div class="card-body"><p></p> <ul class="list-false"> <li>The current lists of operative procedure codes are found on the <a href="/nhsn/acute-care-hospital/ssi/index.html">NHSN Surgical Site Infection (SSI) Events web page</a>.</li> <li>Procedure code documents for the past two years can be found on the <a href="/nhsn/validation/index.html">NHSN Data Validation’s web page</a>.</li> </ul> <p></p></div></div> </div></div></div><a id="NHSN-Procedure-Code-Documents" title="NHSN Procedure Code Documents" class="onThisPageAnchor"></a><h2>NHSN Procedure Code Documents</h2><div id="faq-7022" class="cdc-faq accordion indicator-plus accordion-white mb-3 " role="tablist"><div class="card bar cdc-faq-item" id="faq-7022-1-question"><div class="card card-accordion "><button class="card-header collapsed " data-target="#faq-7022-1-answer" data-toggle="collapse" aria-expanded="false" role="tab" aria-controls="faq-7022-1-answer" data-controls="faq-7022-1-answer"><span class="card-title btn btn-link">Q3: How should facility medical coders use the NHSN procedure code documents for classifying surgical procedures for patient charges?</span></button><div class="collapse d-print-block " collapsed id="faq-7022-1-answer" role="tabpanel"><div class="card-body"><p>The NHSN operative procedure code documents, posted on the NHSN site, are <strong>not intended to be instructive to medical coders for assigning procedure codes</strong> to surgical procedures.  The documents are <strong>provided as a tool </strong>to assist NHSN users participating in SSI reporting with <strong>categorizing operative procedures</strong> by NHSN procedure categories and to <strong>standardize the reporting of surgical procedures </strong>between facilities.</p></div></div> </div></div></div><a id="Updates-to-Procedure-Codes" title="Updates to Procedure Codes" class="onThisPageAnchor"></a><h2>Updates to Procedure Codes</h2><div id="faq-7859" class="cdc-faq accordion indicator-plus accordion-white mb-3 " role="tablist"><div class="card bar cdc-faq-item" id="faq-7859-1-question"><div class="card card-accordion "><button class="card-header collapsed " data-target="#faq-7859-1-answer" data-toggle="collapse" aria-expanded="false" role="tab" aria-controls="faq-7859-1-answer" data-controls="faq-7859-1-answer"><span class="card-title btn btn-link">Q4: When are codes updated and how are users notified of updates?</span></button><div class="collapse d-print-block " collapsed id="faq-7859-1-answer" role="tabpanel"><div class="card-body"><p>NHSN operative procedure codes are reviewed and updated annually and as needed.</p> <p>Communication regarding updates to the operative procedure codes are sent via email to individuals and vendors enrolled in NHSN.  The emails 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.</p></div></div> </div></div></div><a id="Using-Procedure-Codes" title="Using Procedure Codes" class="onThisPageAnchor"></a><h2>Using Procedure Codes</h2><div id="faq-9979" class="cdc-faq accordion indicator-plus accordion-white mb-3 " role="tablist"><div class="card bar cdc-faq-item" id="faq-9979-1-question"><div class="card card-accordion "><button class="card-header collapsed " data-target="#faq-9979-1-answer" data-toggle="collapse" aria-expanded="false" role="tab" aria-controls="faq-9979-1-answer" data-controls="faq-9979-1-answer"><span class="card-title btn btn-link">Q5: Are ICD-10-PCS or CPT procedure codes required to enter SSI events into NHSN?</span></button><div class="collapse d-print-block " collapsed id="faq-9979-1-answer" role="tabpanel"><div class="card-body"><p>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.</p> <p> </p> <p></p></div></div> </div></div><div class="card bar cdc-faq-item" id="faq-9979-2-question"><div class="card card-accordion "><button class="card-header collapsed " data-target="#faq-9979-2-answer" data-toggle="collapse" aria-expanded="false" role="tab" aria-controls="faq-9979-2-answer" data-controls="faq-9979-2-answer"><span class="card-title btn btn-link">Q6: I’m not sure if an operative procedure was correctly coded. What do I do ?</span></button><div class="collapse d-print-block " collapsed id="faq-9979-2-answer" role="tabpanel"><div class="card-body"><p>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.</p> <p> </p> <p></p></div></div> </div></div></div><a id="Scope" title="Scope" class="onThisPageAnchor"></a><h2>Scope</h2><div id="faq-2251" class="cdc-faq accordion indicator-plus accordion-white mb-3 " role="tablist"><div class="card bar cdc-faq-item" id="faq-2251-1-question"><div class="card card-accordion "><button class="card-header collapsed " data-target="#faq-2251-1-answer" data-toggle="collapse" aria-expanded="false" role="tab" aria-controls="faq-2251-1-answer" data-controls="faq-2251-1-answer"><span class="card-title btn btn-link">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?</span></button><div class="collapse d-print-block " collapsed id="faq-2251-1-answer" role="tabpanel"><div class="card-body"><p>Scope is reported based on the primary incision site. If an <strong><em>open and scope</em></strong> code is assigned to procedures in the same NHSN procedure category, then the procedure should be reported to NHSN as <strong>Scope = NO</strong>. The <strong><em>open</em></strong> designation is considered a higher risk procedure.</p></div></div> </div></div><div class="card bar cdc-faq-item" id="faq-2251-2-question"><div class="card card-accordion "><button class="card-header collapsed " data-target="#faq-2251-2-answer" data-toggle="collapse" aria-expanded="false" role="tab" aria-controls="faq-2251-2-answer" data-controls="faq-2251-2-answer"><span class="card-title btn btn-link">Q8: Using the ICD-10-PCS codes, is there a quick way to know when to select “Scope = YES”?</span></button><div class="collapse d-print-block " collapsed id="faq-2251-2-answer" role="tabpanel"><div class="card-body"><p>ICD-10-PCS codes can be helpful in answering the scope question. The fifth character indicates the approach to reach the operative procedure site:</p> <div class="table-responsive"> <table class="table-bordered"> <caption class="caption-top h6 text-center">ICD-10-PCS code for fifth character indicates the approach</caption> <tbody> <tr> <td><strong><span class="d-block text-center">ICD-10 5th Character</span></strong></td> <td><strong><span class="d-block text-center">Approach</span></strong></td> <td><strong><span class="d-block text-center">NHSN Scope Designation</span></strong></td> </tr> <tr> <td><strong><span class="d-block text-center">0</span></strong></td> <td>Open</td> <td class="text-center">NO</td> </tr> <tr> <td class="text-center"><strong>3</strong></td> <td>Percutaneous (Included only in CRAN and VSHN categories- procedures with BURR holes)</td> <td class="text-center">NO</td> </tr> <tr> <td class="text-center"><strong>4</strong></td> <td>Percutaneous endoscopic</td> <td class="text-center">YES</td> </tr> <tr> <td class="text-center"><strong>7</strong></td> <td>Via natural or artificial opening</td> <td class="text-center">NO</td> </tr> <tr> <td class="text-center"><strong>8</strong></td> <td>Via natural or artificial opening with endoscopic</td> <td class="text-center">NO</td> </tr> <tr> <td class="text-center"><strong>F</strong></td> <td>Via natural or artificial opening with percutaneous endoscopic assistance</td> <td class="text-center">YES</td> </tr> </tbody> </table> </div> <p> </p> <p>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.</p></div></div> </div></div></div><a id="HYST" title="HYST" class="onThisPageAnchor"></a><h2>HYST</h2><div id="faq-8900" class="cdc-faq accordion indicator-plus accordion-white mb-3 " role="tablist"><div class="card bar cdc-faq-item" id="faq-8900-1-question"><div class="card card-accordion "><button class="card-header collapsed " data-target="#faq-8900-1-answer" data-toggle="collapse" aria-expanded="false" role="tab" aria-controls="faq-8900-1-answer" data-controls="faq-8900-1-answer"><span class="card-title btn btn-link">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?</span></button><div class="collapse d-print-block " collapsed id="faq-8900-1-answer" role="tabpanel"><div class="card-body"><p>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.</p> <p>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.</p> <p>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.</p> <p>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 <a href="/nhsn/acute-care-hospital/ssi/index.html">NHSN Surveillance for Surgical Site Infection (SSI) Events web page</a> under “Operative Procedure Code Documents”.</p></div></div> </div></div></div><a id="CPT-HYST-Procedures" title="CPT HYST Procedures" class="onThisPageAnchor"></a><h2>CPT HYST Procedures</h2><div id="faq-9098" class="cdc-faq accordion indicator-plus accordion-white mb-3 " role="tablist"><div class="card bar cdc-faq-item" id="faq-9098-1-question"><div class="card card-accordion "><button class="card-header collapsed " data-target="#faq-9098-1-answer" data-toggle="collapse" aria-expanded="false" role="tab" aria-controls="faq-9098-1-answer" data-controls="faq-9098-1-answer"><span class="card-title btn btn-link">Q10: Why are there CPT codes that include “vaginal hysterectomy” in the procedure description included in the HYST-abdominal hysterectomy procedure category?</span></button><div class="collapse d-print-block " collapsed id="faq-9098-1-answer" role="tabpanel"><div class="card-body"><p>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 “<em>laparoscopy, surgical, with <strong>vaginal hysterectomy</strong></em>” 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.</p> <div class="table-responsive"> <table class="table-bordered"> <caption class="caption-top h6 text-center">ICD-10-PCS code for fifth character indicates the approach</caption> <tbody> <tr> <td><strong><span class="d-block text-center">Procedure Category</span></strong></td> <td><strong><span class="d-block text-center">Procedure Code</span></strong></td> <td><strong><span class="d-block text-center">Procedure Code Description</span></strong></td> </tr> <tr> <td><strong><span class="d-block text-center">HYST</span></strong></td> <td><span class="d-block text-center">58550</span></td> <td>Laparoscopy, surgical, with <strong>vaginal hysterectomy</strong>, for uterus 250 g or less</td> </tr> <tr> <td class="text-center"><strong><span class="d-block text-center">HYST</span></strong></td> <td class="text-center"> 58552</td> <td>Laparoscopy, surgical, with <strong>vaginal hysterectomy</strong>, for uterus 250 g or less; with removal of tubes(s) and /or ovary(s)</td> </tr> <tr> <td class="text-center"><strong><span class="d-block text-center">HYST</span></strong></td> <td class="text-center"> 58553</td> <td>Laparoscopy, surgical, with <strong>vaginal hysterectomy</strong>, for uterus greater than 250 g</td> </tr> <tr> <td class="text-center"><strong><span class="d-block text-center">HYST</span></strong></td> <td class="text-center"> 58554</td> <td>Laparoscopy, surgical, with <strong>vaginal hysterectomy</strong>, for uterus greater than 250 g; 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class="collapse"><li class="list-group-item nav-lvl3"><a href="/nhsn/faqs/faq-annual-survey.html">Annual Surveys</a></li><li class="list-group-item nav-lvl3"><a href="/nhsn/faqs/faq-bsi.html">Bloodstream Infection (BSI) Events</a></li><li class="list-group-item nav-lvl3"><a href="/nhsn/faqs/faq-clip.html">Central Line Insertion Practices (CLIP)</a></li><li class="list-group-item nav-lvl3"><a href="/nhsn/faqs/faq-pneu.html">Pneumonia (PNEU) Events</a></li><li class="list-group-item nav-lvl3"><a href="/nhsn/faqs/faq-uti.html">Urinary Tract Infection (UTI) Events</a></li><li class="list-group-item nav-lvl3"><a href="/nhsn/faqs/faq-ssi.html">Surgical Site Infections (SSI) Events</a></li><li class="list-group-item nav-lvl3"><a href="/nhsn/faqs/faq-ssi-proc-codes.html">Surgical Site Procedure Codes</a></li><li class="list-group-item nav-lvl3"><a href="/nhsn/faqs/faq-vae.html">Ventilator-Associated (VAE) Events</a></li><li class="list-group-item nav-lvl3"><a 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nav-lvl2"><a href="/nhsn/ltc/vha/index.html">State Veterans Homes COVID-19 Tool</a></li><li class="list-group-item nav-lvl2"><a href="/nhsn/ltc/cdiff-mrsa/index.html">MDRO & CDI</a></li><li class="list-group-item nav-lvl2"><a href="/nhsn/ltc/uti/index.html">UTI</a></li><li class="list-group-item nav-lvl2"><a href="/nhsn/ltc/process-measures/index.html">Prevention Process Measures</a></li><li class="list-group-item nav-lvl2"><a href="/nhsn/ltc/vaccination/index.html">HCP Flu Vaccination</a></li><li class="list-group-item nav-lvl2"><a href="/nhsn/ltc/validation/index.html">LTCF Data Validation Guidance</a></li><li class="list-group-item nav-lvl2"><a href="/nhsn/ltc/newsletters/index.html">Newsletters & Archived Communications</a><a href="#nav-group-2d3b9" class="nav-plus nav-expandcollapse" data-toggle="collapse" aria-controls="nav-group-2d3b9"><span class="sr-only">plus icon</span><span class="fi cdc-icon-plus" aria-hidden="true"></span></a><ul id="nav-group-2d3b9" class="collapse"><li class="list-group-item nav-lvl3 cdc-nav-item-hidden"><a href="/nhsn/ltc/newsletters/dec20-newsletter-ltc.html">December 2020 LTCF Newsletter</a></li><li class="list-group-item nav-lvl3 cdc-nav-item-hidden"><a href="/nhsn/ltc/newsletters/jul20-newsletter-ltc.html">July 2020 LTCF Newsletter</a></li><li class="list-group-item nav-lvl3 cdc-nav-item-hidden"><a href="/nhsn/ltc/newsletters/mar20-newsletter-ltc.html">March 2020 LTCF Newsletter</a></li><li class="list-group-item nav-lvl3 cdc-nav-item-hidden"><a href="/nhsn/ltc/newsletters/dec19-newsletter-ltc.html">December 2019 LTCF Newsletter</a></li><li class="list-group-item nav-lvl3 cdc-nav-item-hidden"><a href="/nhsn/ltc/newsletters/sep19-newsletter-ltc.html">September 2019 LTCF Newsletter</a></li><li class="list-group-item nav-lvl3 cdc-nav-item-hidden"><a href="/nhsn/ltc/newsletters/jun19-newsletter-ltc.html">June 2019 LTCF Newsletter</a></li><li class="list-group-item nav-lvl3 cdc-nav-item-hidden"><a href="/nhsn/ltc/newsletters/mar19-newsletter-ltc.html">March 2019 LTCF Newsletter</a></li><li class="list-group-item nav-lvl3 cdc-nav-item-hidden"><a href="/nhsn/ltc/newsletters/ltc-email-updates-2018.html">2018 LTCF Email Updates</a></li><li class="list-group-item nav-lvl3 cdc-nav-item-hidden"><a href="/nhsn/ltc/newsletters/dec18-newsletter-ltc.html">December 2018 LTCF Newsletter</a></li><li class="list-group-item nav-lvl3 cdc-nav-item-hidden"><a href="/nhsn/ltc/newsletters/sep18-newsletter-ltc.html">September 2018 LTCF Newsletter</a></li><li class="list-group-item nav-lvl3 cdc-nav-item-hidden"><a href="/nhsn/ltc/newsletters/jun18-newsletter-ltc.html">June 2018 LTCF Newsletter</a></li><li class="list-group-item nav-lvl3 cdc-nav-item-hidden"><a href="/nhsn/ltc/newsletters/march18-newsletter-ltc.html">March 2018 LTCF Newsletter</a></li><li class="list-group-item nav-lvl3 cdc-nav-item-hidden"><a href="/nhsn/ltc/newsletters/ltc-email-updates-2017.html">2017 LTCF Email Updates</a></li><li class="list-group-item nav-lvl3 cdc-nav-item-hidden"><a href="/nhsn/ltc/newsletters/dec-newsletter-ltc.html">December 2017 LTCF Newsletter</a></li><li class="list-group-item nav-lvl3 cdc-nav-item-hidden"><a href="/nhsn/ltc/newsletters/sept-newsletter-ltc.html">September 2017 LTCF Newsletter</a></li></ul></li></ul></li><li class="list-group-item nav-lvl1"><a href="/nhsn/dialysis/index.html">Dialysis Component</a><a href="#nav-group-87595" class="nav-plus nav-expandcollapse" data-toggle="collapse" aria-controls="nav-group-87595"><span class="sr-only">plus icon</span><span class="fi cdc-icon-plus" aria-hidden="true"></span></a><ul id="nav-group-87595" class="collapse"><li class="list-group-item nav-lvl2"><a href="/nhsn/dialysis/covid19/index.html">Dialysis COVID-19 Module</a></li><li class="list-group-item nav-lvl2"><a href="/nhsn/dialysis/pt-covid-vac/index.html">Patient COVID-19 Vaccination</a></li><li class="list-group-item nav-lvl2"><a href="/nhsn/dialysis/event/index.html">Dialysis 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