Dr. Whipple’s Procedure: Helping Patients and Saving Lives Since 1935June 26, 2019
Please Note: The American Hospital Association publication “Coding Clinic for ICD-10-CM/PCS” First Quarter 2019 provides official coding advice on the topic “Whipple Procedure” (page 3). “Coding Clinic for ICD-10-CM/PCS” Third Quarter 2014 provides official advice on the topic “Pyloric-Sparing Whipple Procedure (pages 32-33).
In 2014, the creators of ICD-10- PCS did not include Index references for surgical procedure eponyms, procedural terms derived from the surgeon or surgeons who invented or refined a particular procedure. One example of this is the “Whipple procedure,” so named for its creator, Dr. Allen Oldfather Whipple (1881-1963), who first performed this surgery in 1935 at Columbia Presbyterian Hospital.
Interestingly, the planned surgery was an excision of a stomach tumor. But, when the patient was opened up, Dr. Whipple saw that the tumor was not in the stomach, it was in the pancreas. And so, Dr. Whipple performed the first pancreaticoduodenectomy. Despite this procedure being first performed in 1935, after modifications it remains arguably the best surgical option for treating, and in some cases curing, pancreatic cancer.
Fun Factoid: Dr. Whipple supervised the surgical residency of Dr. Virginia Apgar (born in Westfield, NJ) at Columbia Presbyterian Medical Center. Dr. Apgar is the creator of the “Apgar Score” that is still used today to evaluate newborns.
In today’s coding world, eponyms are still commonly used by surgeons, leaving coders to report the details for each surgical encounter based on the detailed documentation in the operative report.
What Is a Pancreaticoduodenectomy (Whipple Procedure)?
Moving on, we will refer to a “pancreaticoduodenectomy” as a Whipple procedure. “Whipple” just flows better and everyone can say it out loud, but the coder must always know exactly what procedure was performed on each body part involved, and that can vary with each specific operative episode.
Coding Clinic First Quarter 2019 provides four distinct examples in Q&A format to assist coding professionals when assigning and reporting codes for Whipple procedures performed on, for example, patients with different medical histories.
In this blog, we provide a basic overview of the standard or classic Whipple procedure and the pylorus-sparing or pylorus- preserving Whipple procedure, performed on patients with malignant neoplasm of the pancreas. Information about other pancreatic diagnoses and procedures may be found on the University of Pittsburg Hillman Cancer Center website.
The pancreas is an endocrine gland, is about six inches long, and is comprised of three parts – the head, the body and the tail. Approximately 75 percent of primary site pancreatic cancers occur in the head of the pancreas, and would be reported as diagnosis code C25.0 Malignant neoplasm of head of pancreas. Common metastatic sites are the liver and peritoneum, and less commonly the lymph, lung, bone, brain and kidney.
- Note: If the pancreatic cancer has metastasized, it is unlikely that a Whipple procedure will be performed, as the goal of the Whipple is to obtain a surgical cure. Even though a patient is scheduled for a Whipple procedure, the surgeon may not know that the pancreatic cancer has metastasized until the patient has been opened up and their internal organs directly visualized and inspected, or inspected via laparoscopy. If metastases are observed, the surgeon may abandon the plan for a Whipple entirely or perform another procedure to alleviate symptoms, such as for a bile duct obstruction or blockage caused by the pancreatic tumor.
Coding the Whipple Procedure
As always, the coder must read the body of the operative report and report the PCS code or codes for the procedure actually performed, and not simply code from the section of the operative report at the top, “procedure performed.”
If a Whipple procedure was not performed, apply PCS Guideline B3.3 “If the intended procedure is discontinued or otherwise not completed, code the procedure to the root operation performed. If a procedure is discontinued before any other root operation is performed, code the root operation Inspection of the body part or anatomical region inspected.”
In these cases, a possible PCS code for a direct visual inspection would be 0WJG0ZZ for Inspection of Peritoneal Cavity, Open. If a diagnostic laparoscopy was performed, but no other procedure, report 0WJG4ZZ Inspection of peritoneal cavity, percutaneous endoscopic approach. If a procedure other than a Whipple was performed, again refer to the guideline that states “code the procedure to the root operation performed” and report the PCS code for that procedure or procedures, not the Whipple.
When a Whipple procedure is performed, all components of the Whipple procedure must be coded when procedures on separate, individual body parts (organs) are performed. Other organs, in addition to a portion of the pancreas, are removed as part of the Whipple because the pancreas is closely associated with and integrated with these other organs, i.e. the duodenum, gallbladder, a portion of the common bile duct and possibly a portion of the stomach. Aside from the pancreas, these organs may be disease free and not carry a diagnosis.
Root Operations for Whipple Procedures
The Root Operations (character 3 in the PCS code) identify the objective of the procedure for each individual Body Part involved (character 4 in the PCS code). Whipple procedure Root Operations are either Excision or Resection, and will lead to the correct Table for each Body Part, character 4.
If the surgeon documents an “excision” (cutting out or off, without replacement, a portion of a body part) or “resection” (cutting out of or off, without replacement, all of a body part) for the procedure performed on the individual body part, bear in mind that the surgeon may not be describing the procedure in PCS terms; it is the responsibility of the coder to apply the Root Operation definitions for each procedure. If the documentation is not clear, a query may be warranted.
- Note: You may see documentation that the ampulla of Vater was resected. If the entire duodenum was resected, the ampulla of Vater is included in that procedure and is not coded separately. The ampulla of Vater, located at the major duodenal papilla, is also known as the hepatopancreaticampullaor the hepatopancreatic duct, and is formed by the union of the pancreatic duct and the common bile duct.
- Note: The entire pancreas is never removed in any type of Whipple procedure (resection). The Root Operation will always be “excision” for the procedure component involving the pancreas.
A standard, or “classic” Whipple procedure is performed using an Open Approach and typically involves the organs listed below and followed by the PCS code. Note the Root Operations character 3, is either “excision,” character value B, or “resection,” character value T. Note that the Approach character, character 5, is character value 0, for “open.” a removal (excision) of the head of the pancreas, 0FBGOZZ:
- The entire duodenum (resection), 0DT90ZZ
- Entire gallbladder (resection), 0FT40ZZ
- A portion of the common bile duct (excision), 0FB90ZZ
- A portion of the stomach (excision), 0DB60ZZ
Review the operative report and pathology report for any lymphatic excisions, coded as
- Excision of aortic lymphatic, 07BD0ZZ
- Excision of mesenteric lymphatic, 07BB0ZZ
If a diagnostic laparoscopy was performed (prior to the open approach), add
- Inspection of peritoneal cavity, percutaneous endoscopic approach, 0WJG4ZZ
- If laparoscopic, add 8E0W8CZ to indicate robotic assisted procedure, laparoscopic approach. If open, add 8E0W0
- If the Whipple procedure was performed with robotic assistance during the open procedure, add 8E0W0CZ
As technology and surgical techniques evolve, Whipple procedures may be performed laparoscopically with robotic assistance. In these cases, the Approach (character 5), character value is 4, percutaneous endoscopic approach. The code for the robotic assistance is 8E0W8CZ.
Again, at this time it is very unlikely that you will encounter a robotically assisted laparoscopic Whipple procedure. For future reference, see University of Chicago Medicine about their experience with robotic Whipple procedure surgery.
Pylorus-Preserving Whipple (PPPD)
If the documentation in the Whipple operative report reads “modified Whipple,” “pylorus- sparing Whipple,” or “pylorus-preserving pancreaticoduodenectomy,” this typically indicates that the same procedures are performed as for the classic Whipple, with these exceptions:
- A portion of the duodenum (excision) was removed, 0DB90ZZ
- No portion of the stomach was excised, no code
- The stomach pylorus was preserved (not excised or resected), no code
Refer to Coding Clinic Third Quarter 2014, pages 32-33, for previously published advice about the pyloric-sparing Whipple procedure.
Anastomosis and Bypass – Not Coded
When reviewing the operative report, references to “anastomosis” and “bypass” may be documented because the surgeon must reconnect the organs affected. These reconnections may be documented as gastrojejunostomy, pancreaticojejunostomy and choledochojejunostomy, performed to connect the remaining stomach, pancreas and common bile duct to the jejunum.
Since these reconnections, or anastomosis, are required, they are considered inherent to the Whipple procedure and are not coded separately. Any bypasses performed are also not coded separately because “bypass” is not the objective of the Whipple procedure.
The following figures, from the University of Texas, M.D. Anderson Cancer Center, depict the stages of the Whipple; pre-operative and intraoperative. Note that in the third figure, the head of the pancreas, the entire duodenum, the entire gallbladder and part of the stomach have been excised or resected – we know that that this is a classic Whipple because the entire duodenum was resected. The necessary re-attachments, or anastomosis, are depicted in the third figure and although they are part of the complicated Whipple procedure, they are not coded because they are inherent to the procedure.
Figure 1. This figure shows a tumor on the head of the pancreas before Whipple procedure.
Figure 2. This figure shows the surgical separation of the (1) bile duct, (2) stomach, (3) head of the pancreas and (4) small intestine.
Figure 3.This figure shows the re-attachment of the (5) bile duct to the small intestine, (6) remaining pancreas to the small intestine and (7) stomach to the small intestine.
Review the American Hospital Association publication “Coding Clinic for ICD-10-CM/PCS” First Quarter 2019 for the latest, at the time of our blog publication, official coding advice on the topic “Whipple Procedure” (page 3). Refer to “Coding Clinic for ICD-10-CM/PCS” Third Quarter 2014 provides official advice on the topic “Pyloric-Sparing Whipple Procedure (pages 32-33).
A “Whipple Procedure” may be either a classic, standard Whipple procedure, or it may be a “modified Whipple,” “pylorus-sparing Whipple,” or “pylorus-preserving pancreaticoduodenectomy,” (PPPD). The entire operative report must be reviewed in order to code and report the corresponding codes.
Each component of a Whipple procedure must be coded. The Root Operations will be either “Excision” (B) or “Resection” (T).
If the entire duodenum was resected, the ampulla of Vater is included in that procedure and is not coded separately.
Classic Whipple procedures are performed using an Open approach, although there may be very rare exceptions in which a robotic assisted laparoscopic approach is used.
The two main differences between a classic Whipple procedure and a pylorus-sparing Whipple (PPPD) is, first, a portion of the duodenum is removed during the PPPD, whereas the entire duodenum is removed during a classic Whipple. Second, the stomach pylorus is not excised or resected in a PPPD.
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