Transcript Kuehn Nelken Cardiovascular Coding

Cardiovascular Coding with
ICD-10-PCS
Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA
Kuehn Consulting, LLC
Waukesha, WI 53186
(262) 574-1064
l
[email protected]
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Our Topics Today….
• What is ICD-10-PCS and
how does it work?
• Root Operations commonly
performed on
cardiovascular structures
– Definitions
– Details
• Common endovascular
procedures and their
coding
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Procedure Code Structure
Fem-Pop Bypass
with Gore-Tex Graft
ICD-9-CM Procedures
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ICD-10-PCS
9
.
2
9
0 4 1 K 0 J L
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What is ICD-10-PCS?
• ICD-10 (international version) does not
contain a procedure coding system
• CMS contracted to develop a new
procedure coding system
• The new system is intended to replace
ICD-9-CM Volume 3 for reporting inpatient
procedures
• CPT and HCPCS will still be used where
currently in place
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ICD-10-PCS Code Structure
• Codes comprised of seven
components, called characters
• Individual units for each character
have a letter or number assigned as
a “value”
• 34 possible values:
– Digits 0-9
– Letters A-H, J-N, and P-Z
– No I or O
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ICD-10-PCS Code Structure
1
2
3
4
Root
Operation
Section
Body
System
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6
Approach
Body Part
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Qualifier
Device
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ICD-10-PCS Coding Process
• Analyze documentation
• Apply definitions
• Select Root Operation
• Reference Alphabetic Index
• Verify in PCS Table
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Analyze Documentation
Procedure: Right Femoro-Popliteal Above-the-Knee Bypass
with Gore-Tex Graft
This patient had painful cramping in his calf, due to
occlusion of his superficial femoral artery. Due to severe
varicose veins, a prosthetic Gore-Tex graft was used for the
conduit.
Root
Operation
Device
Procedure: After placement of an epidural catheter for
spinal anesthesia, the patient was prepped and draped in Approach
the usual sterile fashion. An incision was made in the
patient’s groin and the right femoral artery was exposed.
An incision was approximately 2 cm about the patient’s knee
joint to expose the popliteal artery. Gore-Tex graft length is
Origin
approximated and tunneled between the two sites. The
graft is sutured to the femoral artery for the proximal
anastomosis and then sutured to the above knee popliteal Destination
artery for the distal anastomosis. Both wounds are closed.
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Alphabetic Index
• Root Operations
• Reference for:
– Body Parts
– Devices
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PCS Table Excerpt - 041
041K0JL Fem-Pop Bypass with Gore-Tex
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System Structure
• Medical and Surgical
• Chiropractic
•
•
•
•
• Imaging
•
•
•
•
Obstetrics
Placement
Administration
Measurement and
Monitoring
Extracorporeal Assistance
and Performance
Extracorporeal Therapies
Osteopathic
Other Procedures
Section
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• Nuclear Medicine
• Radiation Oncology
• Physical Rehabilitation and
Diagnostic Audiology
• Mental Health
• Substance Abuse
Treatment
Body
System
Root
Operation
Body Part
Approach
Device
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Qualifier
Section
• Defines the
general type
of procedure
• Medical and
Surgical
Section
begins with
“0”
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Body System
• Body System or Anatomical Regions
• Examples:
– Lower arteries
– Tendons
– Respiratory system
– Endocrine system
– Upper Joints
Section
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Body
System
Root
Operation
Body Part
Approach
Device
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Qualifier
Root Operation
• Distinct definitions
• Intent of procedure
• Key to coding
Section
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Body
System
Root
Operation
Body Part
Approach
Device
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Qualifier
Med-Surg Root Operations
Alteration
Bypass
Change
Control
Creation
Destruction
Detachment
Dilation
Division
Drainage
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Excision
Extirpation
Extraction
Fragmentation
Fusion
Insertion
Inspection
Map
Occlusion
Reattachment
Release
Removal
Repair
Replacement
Reposition
Resection
Restriction
Revision
Supplement
Transfer
Transplantation
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Body Part
• Anatomical Site of Procedure
• Driven by documentation:
Section
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Body
System
Root
Operation
Body Part
Approach
Device
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Qualifier
Body Part Value Dependent on
Body System Value
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Index by Body Part
• It means that PCS:
– Refers to the external
pudendal artery as the
femoral artery, left or right
– Refers to the external
pudendal vein as the
greater saphenous vein,
left or right
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Body System Vs Body Part
Body System
Body Part
.
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Approach
• Technique used to reach the site of the
procedure
• Approach values:
– Open
– Percutaneous
– Percutaneous Endoscopic
– Via Natural or Artificial Opening
– Via Natural or Artificial Opening Endoscopic
– Via Natural or Artificial Opening with percutaneous
endoscopic assistance
– External
Section
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Body
System
Root
Operation
Body Part
Approach
Device
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Qualifier
Through the Skin
Open
Cutting through the skin or mucous
membrane and any other body layers
necessary to expose the site of the
procedure
Example:
Example:
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Open CABG
Abdominal hysterectomy
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Through the Skin
Percutaneous
Percutaneous
endoscopic
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Entry, by puncture or minor incision, of
instrumentation through the skin or mucous
membrane and any other body layers necessary
to reach the site of the procedure
Example:
Liposuction
Example:
Needle biopsy of liver
Entry, by puncture or minor incision, of
instrumentation through the skin or mucous
membrane and any other body layers necessary
to reach and visualize the site of the procedure
Example:
Laparoscopic cholecystectomy
Example:
Arthroscopy
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Approach Decision Tree
Start
Incision?
Yes
Open
No
Percutaneous
Endoscopic
Yes
Through
Scope?
No
Percutaneous
Yes
Through
Skin?
No
Through
Opening?
No
External
Yes
Through
Scope?
Yes
Via Natural or
Artificial Opening
Endoscopic
No
With
Percutaneous
Endoscopic
Assistance?
Yes
No
Via Natural or Artificial
Opening
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Via Natural or
Artificial Opening
with Percutaneous
Endoscopic
Assistance
Approaches
Open
Percutaneous
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Combined 0pen and Percutaneous
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Device
• Devices that remain after procedure
– Monitoring device
– Intraluminal
– Synthetic
– Autologous tissue
– Nonautologous tissue
Section
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Body
System
Root
Operation
Body Part
Approach
Device
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Qualifier
Device Types
Artificial Sphincter
Endobronchial
valve
Interbody Fusion
Device
Spinal Stabilization Device;
Facet Replacement
Cardiac Lead
Endotracheal
airway
Internal Fixation
Device
Cardiac Rhythm
Related Device
External Fixation
Device
Contraceptive
Device
Extraluminal
Device
Intramedullary
Internal Fixation
Device
Spinal Stabilization Device;
Interspinous Process
Device
Contractility
Modulation Device
Defibrillator
Diaphragmatic
pacemaker lead
Drainage Device
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Spinal Stabilization Device;
Pedicle-Based Device
Liner
Stimulator Generator
Feeding Device
Monitoring Device
Stimulator Lead
Hearing Device,
Bone Conduction
Pacemaker, Single
or Dual
Tracheostomy device
Radioactive
Element
Vascular Access Device,
Reservoir or Pump
Hearing Device,
Cochlear
Prosthesis
Infusion device
Spacer
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Qualifier
• Additional attribute
• Narrow application
• Examples:
–Source of transplanted tissue
–Diagnostic
–Other additional data
Section
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Body
System
Root
Operation
Body Part
Approach
Device
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Qualifier
5 PCS Tables
• Heart and Great Vessels
• Upper Arteries
• Lower Arteries
• Upper Veins
• Lower Veins
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Axillo-Femoral Bypass
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• Femoral Femoral
component
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Excision
Explanation:
Definition: Cutting out
or off, without
replacement, A PORTION The qualifier Diagnostic is
used to identify excision
OF a body part
procedures that are
biopsies.
Uses sharp instrument
such as scalpel, wire,
Examples:
scissors, bone saw,
• Sigmoid polypectomy
electrocautery tip
• Renal biopsy
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Resection
Definition:
Examples:
• Total nephrectomy
Cutting out or off,
• Total lobectomy of lung
without replacement,
ALL of a body part
Note: Lobes of the
lung are the complete
body part. Body part
is not always the
same as entire organ.
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Destruction
Definition:
Examples:
Physical eradication of all
or a portion of a body
part by the direct use of
energy, force or a
destructive agent.
• Fulguration of bleeder
• Cautery of skin lesion
• Cryocautery of lesion
Note: None of the body
part is physically taken
out. There is no tissue to
be sent for pathology
because the tissue is
destroyed.
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Case to Code
The surgeon harvests the left radial
artery through an incision for use in
another simultaneous procedure.
What root operation is this?
Excision
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03B Table Excerpt
03BC0ZZ
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Surgeon Note:
• Linguistically, we often transpose
resection and excision. I personally
would probably dictate this as a
resection whether or not this fits
with your coding rules.
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Extraction
• Definition: Pulling or stripping out or
off all or a portion of a body part by
the use of force
• Explanation: The qualifier Diagnostic
is used to identify extraction
procedures that are biopsies
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Root Operations – Extraction
• Classic examples:
– Tooth extraction
– Vein stripping
• More challenging
examples:
– Bone marrow or
endometrial biopsy
– Removal of intraocular
lens without replacement
by implant
– Non-excisional
debridement of skin
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Extraction: Surgeon comments
Stripping
Deep System
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Stab Phlebectomy
Superficial system
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Extirpation
Definition:
Taking or
cutting out
solid matter
from a body
part
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Explanation:
The solid matter may be
an abnormal byproduct of a
biological function or a foreign body.
The solid matter may or may not
have been previously broken into
pieces. No appreciable amount of the
body part is taken out.
Examples:
•Thrombectomy
•Choledocholithotomy
•Removal of retained, infected suture
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Extirpation
The objective is to remove solid material such as a
foreign body, thrombus, or calculus from the body part.
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Carotid Endarterectomy
Root operation = Extirpation
Sources: http://www.nhlbi.nih.gov/health/health-topics/topics/carend/ and
http://www.mayoclinic.com/health/medical/IM01657
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03C Table Excerpt
Let’s code that last picture: Open
endarterectomy of the right internal carotid
artery
03CK0ZZ
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Root Operation Group
• Procedures that alter the
diameter/route/of a tubular body
part
–Restriction
–Occlusion
–Dilation
–Bypass
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Tubular Body Parts
• Hollow structures that carry fluid or
gas/air
• No openings – Circulatory and
Lymphatic systems
• Opening at one end – Respiratory
and nose, Genitourinary, ear canal
• Opening at both ends – GI system,
including hepatobiliary tree
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Restriction
• Definition: Partially closing the orifice or
lumen of a tubular body part
• Explanation: The orifice can be a natural
orifice or an artificially created orifice
• Classic examples:
– Esophagogastric fundoplication
– Cervical cerclage
• More challenging example:
– Clipping of cerebral aneurysm
– Placement of restrictive stent in lacrimal duct
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Restriction
• Endovascular
Coil placement
• Root operation
= Restriction
• Device =
Intraluminal
device
Percutaneous Restriction
(Coiling)
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Surgeon Notes: Banding
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Endovascular “Repair”
Abdominal Aortic Aneurysm
• Intraluminal
device
• Bifurcated
prosthesis
• Root operation
= Restriction
• Device =
Intraluminal
device
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Case to Code
The surgeon performs a clipping of an unruptured
aneurysm of the basilar artery via a craniotomy.
What root operation is this?
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03V Table
03VG0CZ
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Occlusion
Definition:
Completely
closing the orifice or
lumen of a tubular body
part
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Explanation:
The orifice can
be a natural orifice or an
artificially created orifice.
Examples:
•Fallopian tube ligation
•Embolization of vascular
supply, intracranial
meningioma
•Ligation of inferior vena
cava
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Occlusion
• The root operation Occlusion is coded
when the objective of the procedure is to
close off a tubular body part or orifice.
• Occlusion includes both intraluminal and
extraluminal methods of closing off the body
part.
• Division of the tubular body part prior to
closing it is an integral part of the Occlusion
procedure.
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Surgeon Notes Restriction vs. Occlusion
for embolization
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Endovenous Laser Treatment
Through a tiny incision at the knee, a small tube is placed into
the greater saphenous vein. Then, a laser or radiofrequency
fiber is passed through the tube into the vein. Once in place,
the fiber is activated, delivering very localized heat to the vein
wall. In response, the vein closes down and becomes
permanently blocked.
Source: http://www.ohsu.edu/dotter/venous_ablation.htm
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06L Table
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Dilation
Definition:
Expa
nding an orifice or
the lumen of a
tubular body part
Explanation:
The orifice can be a
natural orifice or an artificially
created orifice. Accomplished by
stretching a tubular body part
using intraluminal pressure or by
cutting part of the orifice or wall
of the tubular body part.
Examples:
•Percutaneous transluminal
angioplasty with or without stent
•Pyloromyotomy
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Coronary Sites Treated
Coding Note: In ICD-10PCS, the classification of
the coronary arteries is as
a single body part. It
doesn’t matter what the
number of arteries treated
is (i.e., right coronary
artery, left anterior
descending, or left
circumflex, or the
branches). The
distinguishing factor is the
number of sites treated.
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Percutaneous Transluminal
Coronary Angioplasty (PTCA) and
Stenting
Therapeutic procedure
used to treat the
stenotic (narrowed)
coronary arteries
found in coronary
heart disease.
Root Operation =
Dilation
Device = Various types
of intraluminal
devices
Source: http://www.infobarrel.com/Risk_factors_and_the_management_of_Angina
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Different Devices?
• What if different devices are used on
different sites?
• ICD-10-PCS Guidelines tell us:
– Anytime a body part, approach, device
or qualifier is different, separate codes
are assigned
– Dilate two unique body part values =
two codes
– Dilate two sites of a body part using
different devices = two codes
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Case to Code
The cardiologist stents two sites, proximal
and mid, of the left anterior descending
artery with CYPHER drug-eluting stents.
What root operation is this?
Dilation
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027 Table
027134Z
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Bypass
• Definition: Altering the route of passage of
the contents of a tubular body part
• Explanation: Rerouting contents around an
area of a body part to another distal
(downstream) area in the normal route;
rerouting the contents to another different
but similar route and body part; or to an
abnormal route and another dissimilar body
part. It includes one or more concurrent
anastomoses with or without the use of a
device such as autografts, tissue substitutes
and synthetic substitutes
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Bypass
• Classic examples:
– Coronary artery bypass
– AV fistula or graft creation
Type of
Tissue
Autologous
(vein or
artery)
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Device Definition
Charact
er
9 or A Referring to a graft
in which the donor
& recipient areas
are in the same
individual
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Coronary Artery Bypass Grafting
• CABG (Bypass)
• Free Vein Graft:
– Greater Saphenous
Vein
• Free Artery Grafts:
– Right Internal
Mammary
– Radial Artery
• Pedicle Artery Graft:
– Left Internal
Mammary artery
Source: http://www.hakeem-sy.com/main/node/25417
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Bypass
Non-Coronary
Body Part
FROM
Qualifier
TO
Coronary Sites
Body Part
Qualifier
NUMBER OF
SITES
FROM
Coronary Artery
Downstream route
Reminder: The
excision of the autograft is
coded as a separate
procedure. (Guideline B3.9)
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Axillo-Femoral Bypass
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• Femoral Femoral
component
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Axillo-Femoral Bypass
Synthetic substitute used to create bypass
Right axillary artery to upper leg artery, right = 03150J6
Right axillary artery to upper leg artery, bilateral = 03150J8
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Case to Code
Procedure:
CABG
Description of Procedure: The chest was opened through a median
sternotomy incision. The pericardium was opened. Cardiopulmonary
bypass was initiated. The greater saphenous vein was harvested via
incision from the left lower extremity. The patient was cooled and
cross-clamped. The cold blood cardioplegia solution was administered.
Individual segments of saphenous vein were sewn to the obtuse
marginal, to the posterolateral branch of the circumflex artery, and to
the distal right coronary artery respectively. Each of these
anastomoses were carried out with running sutures of 7-0 Prolene.
At the termination of this, warm blood cardioplegia was administered
and the aortic cross-clamp was then released. A partial occluding
clamp was placed on the aorta. Three buttons of aortic tissue were
excised and used as three proximal anastomoses for the saphenous
grafts which were carried out with running sutures of 6-0 Prolene.
With the patient fully re-warmed, the heart resumed a good
contractility and resumed a normal sinus rhythm. The patient was
weaned from cardiopulmonary bypass. The chest was closed in layers
in the usual fashion and dry sterile dressing was applied.
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CABG
How many procedures
must be coded?
Three
What are the root
operations?
Bypass
Excision
Performance
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Answers
021209W, 06BQ0ZZ, 5A1221Z
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Insertion
Definition:
Putting in a nonbiological appliance that
monitors, assists,
performs, or prevents a
physiological function
but does not physically
take the place of a body
part
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Examples:
• Insertion of:
–radioactive implant
–central venous catheter
–Pacemaker
Note: Index states
“Insertion of device in….”
to remind you that this
always involves a device
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Insertion
The root operation Insertion
represents those procedures
where the sole objective is to put
in a device without doing
anything else to a body part.
Procedures typical of those coded
to Insertion include putting in a
vascular catheter, a pacemaker
lead, or a tissue expander.
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Perm-A-Cath
Central Venous Catheter
(Infusion Device)
Insertion, Heart and great vessels,
infusion device
Code body part as where catheter stops
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Reservoir and Pump
Implantable VAD
Reservoir
Insertion, SubQ,
Vascular access
device
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Implantable VAD Reservoir
and Pump
Insertion, SubQ,
Infusion device, pump
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Pacemaker
• Medical device that delivers
electrical impulses to the
heart muscles using
electrodes
• Regulates the beating of the
heart
• Maintains an adequate heart
rate when:
– Heart too slow
– Block in conduction
mechanism
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Defibrillator
• An implantable cardioverterdefibrillator (ICD) is a small
battery-powered electrical
impulse generator:
– Patient at risk for sudden
cardiac death due to:
•Ventricular
fibrillation
•Ventricular
tachycardia
• Programmed to detect
cardiac arrhythmia and
correct it by delivering a jolt
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Removal
• Definition: Taking out or off a device from a
body part
• Explanation: The procedure for taking out
the device is coded to the root operation
Removal and the procedure for putting in
the new device is coded to the root
operation performed.
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Removal
• Classic examples:
– Drainage tube removal
– Cardiac pacemaker removal
• More challenging examples:
– Removal of infected surgical mesh, or
neurostimulator lead
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Case to Code
PROCEDURE: Pacemaker generator replacement.
PROCEDURE IN DETAIL: With the patient under monitored
anesthesia care, the patient's left upper chest and neck were
sterilely prepped. The previous pacemaker scar was incised.
The subcutaneous tissues were divided with electrocautery.
The fibrous capsule was opened and the pacemaker
explanted. The lead was loosened and removed from the
pacemaker generator and quickly attached to the pacemaker
cable for pacing and testing, as the patient is pacemaker
dependent. Pacing parameters were excellent. The lead was
then inserted into the receptacle of the pacemaker generator
and tightened down.
The pocket was irrigated with antibiotic solution. Hemostasis
was good. The generator was inserted into the pocket. The
incision was closed in layers with continuous Vicryl sutures
including the subcuticular layer.
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Pacemaker
How many procedures
are there?
Two
What are the root
operations?
1.Removal (of device
from…)
2.Insertion
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0JP Table
0JPT0PZ
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0JH Table
0JH604Z
Leads are not changed – if done, additional code(s)
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Replacement
• If the body part has been previously
replaced, a separate Removal procedure is
coded for taking out the device used in
the previous replacement
• Classic examples:
– Total hip replacement,
– Bone graft or free skin graft
• More challenging examples:
– Corneal transplant from donor
– Mitral valve replacement, porcine valve
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Cardiac Valve Replacement
• Biologic vs.
Mechanical
Replacement
– Aortic Valve
– Tricuspid Valve
– Mitral Valve
• Root Operation =
Replacement
• Device = Synthetic or
Zooplastic
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Supplement
• Definition: Putting in or on biological or
synthetic material that physically reinforces
or augments the function of a body part
• Explanation: The biological material is
non-living, or the biological material is living
and from the same individual. The body part
may have been previously replaced. If the
body part has been previously replaced, the
Supplement procedure is performed to
physically reinforce and/or augment the
function of the replaced body part
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Supplement
• Classic examples:
– Herniorrhaphy using
mesh
– Free nerve graft
– Mitral valve ring
annuloplasty
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Atrial Septal Defect Closure
• Catheter Based:
– Femoral vein
– Double “Umbrella”
Closure device
• Open surgical
approach:
– Dacron Patch
• Root operation =
Supplement
• Device = Synthetic
Source: http://www.scubamed.com/PFO_page.html
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Case to Code
The surgeon performs
open heart surgery to
repair an atrial septal
defect with mesh. What
root operation is this?
Supplement
Which body part value
will we pick?
Atrial septum
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02U Table
02U50JZ
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Supplement Examples
Not a stent
Wrapping, whether inside or
outside the vessel, is
Supplement
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Surgeon Note:
• I have trouble with this.
• We don’t call this supplementation,
and don’t conceive of it this way.
This is an aneurysm exclusion or and
aneurysm replacement in our
language
• The wrapping is for convenience
really and other more subtle
functions. It is NOT the purpose of
this operation.
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Repair
Definition:
Explanation:
Resto
ring, to the
extent possible,
a body part to
its normal
anatomic
structure and
function
Used only
when the method to
accomplish the repair is
not one of the other root
operations
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Examples:
•Suture of VSD
•Suture of laceration
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Cardiac Valve Repair
• Repair
–Using sutures
• Root operation =
Repair
Source: http://www.heart-valve-surgery.com/heart-valve-repair-valvuloplasty-annuloplasty.php
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Repair Decision Tree
Procedure performed
to restore body part
Body part
remains in
place?
No
Code root
operation
performed, such
as Replacement
Yes
Body part
No
reinforced with
device?
Code
Repair
Yes
Code
Supplement
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Name That Root!
• Endovascular laser
treatment
– Occlusion
• Clamping of artery
for patient with
aneurysm
– Restriction
• Suture of
laceration of artery
• Heart valve
annuloplasty
– Supplement
• Angioplasty for
plaque
– Dilation
• Pacemaker
placement
– Insertion
– Repair
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Review Questions
A patient has a PTCA of two sites of
the LAD utilizing one drug-eluting
stent and one bare metal stent. How
many codes are assigned?
A.One
B.Two
C.Need additional information
Answer: B. Two
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Review Questions
In CABG procedures, the 4th character
(body part) indicates:
A.The location that the blood is flowing
“from”
B.The number of sites treated
C.Need additional information
Answer: B. The body part indicates
the number of sites treated.
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Review Questions
In pacemaker insertion procedures,
the pacemaker is inserted into the:
A.Chest wall
B.Subcutaneous tissue of the chest
C.Heart
D.Atrium or Ventricle
Answer: B. Subcutaneous
tissue of the chest
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Thank you!
Contact Information:
Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA
Kuehn Consulting, LLC
1155 S. Springdale Road Waukesha, WI
53186
O: 262-574-1064
F: 262-574-0828
[email protected]
www.KuehnConsulting.com
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