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Surgery procedure code


Data Element ID: DE456
Name: Surgery procedure code
Version: Hospital Version 1.1, Hospital Version 1.2
Data Element ISO Name: Event_Surgery-code,CD
Definition: The ICD-9-CM or ICD-10-CM procedure code associated with this event.
Question: Enter ICD-9-CM or ICD-10-CM procedure code associated with this event (if available ):
Multiple Choice: No
Form Name: Surgery or Anesthesia
Setting: Hospitals, including outpatient pharmacies and outpatient departments located within the hospital
Comments: None defined at this time
Description of Change: Changed the Data Element Question from "Enter ICD-9-CM procedure code associated with this event:" to "Enter ICD-9-CM or ICD-10-CM procedure code associated with this event (if available):";
Changed the Definition from "The ICD-9-CM procedure code associated with this event." to "The ICD-9-CM or ICD-10-CM procedure code associated with this event."
Go-To Logic: Refer to Common Formats Flow Charts
Guide For Use: Enter the ICD-9-CM or ICD-10-PCS code for the procedure associated with the event. Since the procedure associated with the event need not be the principal procedure of the hospital stay, this code may be assigned prior to discharge.
If there is no invasive procedure associated with the event, but anesthesia was administered for a non-invasive procedure and the event involved the administration of anesthesia, enter the code for the non-invasive procedure.
If the event involved the administration of anesthesia and no other procedure, enter the procedure code for the administration of anesthesia.
If the event involved only a non-invasive procedure, i.e., neither an invasive procedure nor the administration of anesthesia, the 'Surgery or Anesthesia' Common Formats should not be used.
Format: Refer to Common Formats Technical Specifications - Appendix A: Resource Workbook (Validation Tab)
HL7 Data Type: Concept Descriptor (CD)
Data Type: Character
Maximum Length: 7
Answer Code Answer ID Answer Value Code System Code System Name
Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable
Effective Date: 03/31/2010
Until Date: - -
Update Date: 04/24/2013
Source: Agency for Healthcare Research and Quality
Submitting Organization: Agency for Healthcare Research and Quality (AHRQ)
Date of Submission: - -
Responsible Organization: Agency for Healthcare Research and Quality (AHRQ)
Creator: Amy Helwig, MD, MS
Data Steward: Agency for Healthcare Research and Quality (AHRQ)
References: Responses to this question are values from the ICD-9-CM (procedure codes) or ICD-10-CM (procedure codes) Code Systems (Code System OID: 2.16.840.1.113883.6.104 or 2.16.840.1.113883.6.4)
Rationale for Change: Data Element Question clarification;
Data Element Definition clarification;
Increased narrative field size to accommodate more information
Administrative Status: Final
Administrative Status Date: 04/03/2012
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