Cardiovascular Coding with ICD-10-PCS Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA Kuehn Consulting, LLC Waukesha, WI 53186 (262) 574-1064 l LKuehn1@wi.rr.com 1 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 © Kuehn Consulting, LLC 2 Procedure Code Structure Fem-Pop Bypass with Gore-Tex Graft ICD-9-CM Procedures 3 ICD-10-PCS 9 . 2 9 0 4 1 K 0 J L © Kuehn Consulting, LLC 3 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 © Kuehn Consulting, LLC 4 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 © Kuehn Consulting, LLC 5 ICD-10-PCS Code Structure 1 2 3 4 Root Operation Section Body System © Kuehn Consulting, LLC 5 6 Approach Body Part 7 Qualifier Device 6 ICD-10-PCS Coding Process • Analyze documentation • Apply definitions • Select Root Operation • Reference Alphabetic Index • Verify in PCS Table © Kuehn Consulting, LLC 7 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. © Kuehn Consulting, LLC 8 Alphabetic Index • Root Operations • Reference for: – Body Parts – Devices © Kuehn Consulting, LLC 9 PCS Table Excerpt - 041 041K0JL Fem-Pop Bypass with Gore-Tex © Kuehn Consulting, LLC 10 System Structure • Medical and Surgical • Chiropractic • • • • • Imaging • • • • Obstetrics Placement Administration Measurement and Monitoring Extracorporeal Assistance and Performance Extracorporeal Therapies Osteopathic Other Procedures Section © Kuehn Consulting, LLC • Nuclear Medicine • Radiation Oncology • Physical Rehabilitation and Diagnostic Audiology • Mental Health • Substance Abuse Treatment Body System Root Operation Body Part Approach Device 11 Qualifier Section • Defines the general type of procedure • Medical and Surgical Section begins with “0” © Kuehn Consulting, LLC 12 Body System • Body System or Anatomical Regions • Examples: – Lower arteries – Tendons – Respiratory system – Endocrine system – Upper Joints Section © Kuehn Consulting, LLC Body System Root Operation Body Part Approach Device 13 Qualifier Root Operation • Distinct definitions • Intent of procedure • Key to coding Section © Kuehn Consulting, LLC Body System Root Operation Body Part Approach Device 14 Qualifier Med-Surg Root Operations Alteration Bypass Change Control Creation Destruction Detachment Dilation Division Drainage © Kuehn Consulting, LLC Excision Extirpation Extraction Fragmentation Fusion Insertion Inspection Map Occlusion Reattachment Release Removal Repair Replacement Reposition Resection Restriction Revision Supplement Transfer Transplantation 15 Body Part • Anatomical Site of Procedure • Driven by documentation: Section © Kuehn Consulting, LLC Body System Root Operation Body Part Approach Device 16 Qualifier Body Part Value Dependent on Body System Value © Kuehn Consulting, LLC 17 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 © Kuehn Consulting, LLC 18 Body System Vs Body Part Body System Body Part . © Kuehn Consulting, LLC 19 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 © Kuehn Consulting, LLC Body System Root Operation Body Part Approach Device 20 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: © Kuehn Consulting, LLC Open CABG Abdominal hysterectomy 21 Through the Skin Percutaneous Percutaneous endoscopic © Kuehn Consulting, LLC 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 22 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 ©Kuehn Consulting, LLC Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance Approaches Open Percutaneous © Kuehn Consulting, LLC 24 Combined 0pen and Percutaneous © Kuehn Consulting, LLC 25 Device • Devices that remain after procedure – Monitoring device – Intraluminal – Synthetic – Autologous tissue – Nonautologous tissue Section © Kuehn Consulting, LLC Body System Root Operation Body Part Approach Device 26 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 © Kuehn Consulting, LLC 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 27 Qualifier • Additional attribute • Narrow application • Examples: –Source of transplanted tissue –Diagnostic –Other additional data Section © Kuehn Consulting, LLC Body System Root Operation Body Part Approach Device 28 Qualifier 5 PCS Tables • Heart and Great Vessels • Upper Arteries • Lower Arteries • Upper Veins • Lower Veins © Kuehn Consulting, LLC 29 Axillo-Femoral Bypass © Kuehn Consulting, LLC • Femoral Femoral component 30 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 © Kuehn Consulting, LLC 31 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. © Kuehn Consulting, LLC 32 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. © Kuehn Consulting, LLC 33 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 © Kuehn Consulting, LLC 34 03B Table Excerpt 03BC0ZZ © Kuehn Consulting, LLC 35 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. © Kuehn Consulting, LLC 36 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 © Kuehn Consulting, LLC 37 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 © Kuehn Consulting, LLC 38 Extraction: Surgeon comments Stripping Deep System © Kuehn Consulting, LLC Stab Phlebectomy Superficial system 39 Extirpation Definition: Taking or cutting out solid matter from a body part © Kuehn Consulting, LLC 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 40 Extirpation The objective is to remove solid material such as a foreign body, thrombus, or calculus from the body part. © Kuehn Consulting, LLC 41 Carotid Endarterectomy Root operation = Extirpation Sources: http://www.nhlbi.nih.gov/health/health-topics/topics/carend/ and http://www.mayoclinic.com/health/medical/IM01657 © Kuehn Consulting, LLC 42 03C Table Excerpt Let’s code that last picture: Open endarterectomy of the right internal carotid artery 03CK0ZZ © Kuehn Consulting, LLC 43 Root Operation Group • Procedures that alter the diameter/route/of a tubular body part –Restriction –Occlusion –Dilation –Bypass © Kuehn Consulting, LLC 44 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 © Kuehn Consulting, LLC 45 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 © Kuehn Consulting, LLC 46 Restriction • Endovascular Coil placement • Root operation = Restriction • Device = Intraluminal device Percutaneous Restriction (Coiling) © Kuehn Consulting, LLC 47 Surgeon Notes: Banding © Kuehn Consulting, LLC 48 48 Endovascular “Repair” Abdominal Aortic Aneurysm • Intraluminal device • Bifurcated prosthesis • Root operation = Restriction • Device = Intraluminal device © Kuehn Consulting, LLC 49 Case to Code The surgeon performs a clipping of an unruptured aneurysm of the basilar artery via a craniotomy. What root operation is this? © Kuehn Consulting, LLC 50 03V Table 03VG0CZ © Kuehn Consulting, LLC 51 Occlusion Definition: Completely closing the orifice or lumen of a tubular body part © Kuehn Consulting, LLC 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 52 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. © Kuehn Consulting, LLC 53 Surgeon Notes Restriction vs. Occlusion for embolization © Kuehn Consulting, LLC 54 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 © Kuehn Consulting, LLC 55 06L Table © Kuehn Consulting, LLC 56 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 © Kuehn Consulting, LLC 57 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. © Kuehn Consulting, LLC 58 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 © Kuehn Consulting, LLC 59 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 © Kuehn Consulting, LLC 60 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 © Kuehn Consulting, LLC 61 027 Table 027134Z © Kuehn Consulting, LLC 62 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 © Kuehn Consulting, LLC 63 Bypass • Classic examples: – Coronary artery bypass – AV fistula or graft creation Type of Tissue Autologous (vein or artery) © Kuehn Consulting, LLC Device Definition Charact er 9 or A Referring to a graft in which the donor & recipient areas are in the same individual 64 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 © Kuehn Consulting, LLC 65 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) © Kuehn Consulting, LLC 66 Axillo-Femoral Bypass © Kuehn Consulting, LLC • Femoral Femoral component 67 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 © Kuehn Consulting, LLC 68 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. © Kuehn Consulting, LLC 69 CABG How many procedures must be coded? Three What are the root operations? Bypass Excision Performance © Kuehn Consulting, LLC 70 Answers 021209W, 06BQ0ZZ, 5A1221Z © Kuehn Consulting, LLC 71 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 © Kuehn Consulting, LLC 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 72 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. © Kuehn Consulting, LLC 73 Perm-A-Cath Central Venous Catheter (Infusion Device) Insertion, Heart and great vessels, infusion device Code body part as where catheter stops © Kuehn Consulting, LLC 74 Reservoir and Pump Implantable VAD Reservoir Insertion, SubQ, Vascular access device © Kuehn Consulting, LLC Implantable VAD Reservoir and Pump Insertion, SubQ, Infusion device, pump 75 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 © Kuehn Consulting, LLC 76 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 © Kuehn Consulting, LLC 77 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. © Kuehn Consulting, LLC 78 Removal • Classic examples: – Drainage tube removal – Cardiac pacemaker removal • More challenging examples: – Removal of infected surgical mesh, or neurostimulator lead © Kuehn Consulting, LLC 79 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. © Kuehn Consulting, LLC 80 Pacemaker How many procedures are there? Two What are the root operations? 1.Removal (of device from…) 2.Insertion © Kuehn Consulting, LLC 81 0JP Table 0JPT0PZ © Kuehn Consulting, LLC 82 0JH Table 0JH604Z Leads are not changed – if done, additional code(s) © Kuehn Consulting, LLC 83 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 © Kuehn Consulting, LLC 84 Cardiac Valve Replacement • Biologic vs. Mechanical Replacement – Aortic Valve – Tricuspid Valve – Mitral Valve • Root Operation = Replacement • Device = Synthetic or Zooplastic © Kuehn Consulting, LLC 85 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 © Kuehn Consulting, LLC 86 Supplement • Classic examples: – Herniorrhaphy using mesh – Free nerve graft – Mitral valve ring annuloplasty © Kuehn Consulting, LLC 87 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 © Kuehn Consulting, LLC 88 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 © Kuehn Consulting, LLC 89 02U Table 02U50JZ © Kuehn Consulting, LLC 90 Supplement Examples Not a stent Wrapping, whether inside or outside the vessel, is Supplement © Kuehn Consulting, LLC 91 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. © Kuehn Consulting, LLC 92 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 © Kuehn Consulting, LLC Examples: •Suture of VSD •Suture of laceration 93 Cardiac Valve Repair • Repair –Using sutures • Root operation = Repair Source: http://www.heart-valve-surgery.com/heart-valve-repair-valvuloplasty-annuloplasty.php © Kuehn Consulting, LLC 94 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 © Kuehn Consulting, LLC 95 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 © Kuehn Consulting, LLC 96 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 © Kuehn Consulting, LLC 97 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. © Kuehn Consulting, LLC 98 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 © Kuehn Consulting, LLC 99 © Kuehn Consulting, LLC 100 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 lkuehn1@wi.rr.com www.KuehnConsulting.com © Kuehn Consulting, LLC 101