A patient presents for an esophagogastroduodenoscopy (EGD), a diagnostic procedure that allows the physician to diagnose and treat problems in the upper gastrointestinal (UGI) tract. The physician inserts the endoscope and navigates through the patient's mouth and throat, then through the esophagus, stomach, and duodenum.
The physician found esophageal varices, abnormal, enlarged veins in the lower part of the esophagus. Esophageal varices can spontaneously rupture, resulting in severe bleeding. The physician uses bands placed via a band ligation device to completely close off the varices. How would you code this procedure in ICD-10-PCS?
Procedure codes are not assigned; they are built character-by-character, says Nena Scott, MSEd, RHIA, CCS, CCS-P, AHIMA-approved ICD-10-CM/PCS trainer, director of education at TrustHCS in Springfield, Missouri. “This build depends on the complexity of the procedure, and even more importantly, the comprehensiveness and clarity of the physician’s documentation.”
Building the code
The first thing you need to determine is the body part. Should this procedure be coded using a code for the GI system (ICD-10-PCS second character D) or lower veins (second character 6)? And which ICD-10-PCS root operation should be reported?
The root operation choice is fairly straightforward, says Gretchen Young-Charles, RHIA, senior coding consultant for the American Hospital Association (AHA) in Chicago. When the physician snares the varices using a band, he or she is completely stopping the flow of blood. That meets the definition of root operation Occlusion (ICD-10-PCS third character L), which is completely closing an orifice or the lumen of a tubular body part.
That still leaves the question of the body part, and the possible ICD-10-PCS tables for the procedure may confuse you.
In table 04L (Occlusion of the lower arteries), the possible approaches are:
- 0, open: cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure
- 3, percutaneous: 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
- 4, percutaneous endoscopic: 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
The main difference between a percutaneous and percutaneous endoscopic approaches is the visualization of the procedure site, says Scott. The percutaneous endoscopic approach includes visualization of the site.
Based on the definitions of the approaches, none seem to match the documented procedure, says Young-Charles.
If you look at table 0DL (Occlusion of the GI system), you don’t see a device character that matches the band, Young-Charles says. “Both tables have some elements of the procedure, but neither table includes all of the elements.”
Which table should you use? Look closely at the procedure and see what is actually being closed off, Young-Charles says. The physician is closing off the vein, not the esophagus. The correct body part is 6, so you will build a code using table 06L, even though the table does not contain an approach for a natural or artificial orifice. The best approach character to use is percutaneous endoscopic, Young-Charles says.
That makes the final code 06L34CZ (Occlusion of esophageal vein with extraluminal device, percutaneous endoscopic approach). See Coding Clinic, Fourth Quarter 2013, pp. 112-113.
Injection of sclerosing agent into an esophageal varix
Instead of occluding a varix, the physician can instead inject a sclerosing agent into the vessel. When injected into the veins, the sclerosing agent causes blood clots to form and stops the bleeding.
When injected into the area beside the distended vein, the sclerosing agent thickens and swells the vein to compress the blood vessel.
The procedure begins the same way as the banding procedure, with the physician inserting the endoscope into the patient’s mouth and guiding it through the esophagus to identify the vein(s) where the varices are. The physician then uses a needle to inject the sclerosing agent into the vein or surrounding tissue.
The objective of the procedure is to stop the blood flow, just as with the banding procedure. However, injecting the sclerosing agent does not meet the definition of an Occlusion procedure.
Instead, you need to look at two different root operations, Young-Charles says:
- Introduction: putting in or on a therapeutic, diagnostic, nutritional, physiological, or prophylactic substance except blood or blood products
- Destruction: physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent
None of the body part is physically taken out in a Destruction procedure. Destruction "takes out" a body part in the sense that it obliterates the body part so it is no longer there.
In this case, the physician is not physically eradicating the blood vessel. Instead, the physician is injecting an agent into the vein or surrounding tissue, so the correct root operation is Introduction, Young-Charles says.
The correct ICD-10-PCS code for this procedure is 3E0G8TZ (Introduction of destructive agent into upper GI, via natural or artificial opening endoscopic), Young-Charles says.
Note that this code is not in the Medical and Surgical section of ICD-10-PCS. Instead, you will find it in the Administration section. While the Medical and Surgical section includes 31 root operations, the Administration section has only three, Scott says.
The majority of the codes in the Administration section involve Introduction, such as infusion of chemotherapy, Scott says. You will also find codes for transfusions and irrigation in this section.
The first five characters represent the same information in the Medical and Surgical section and the Administration section.
The first character is the section.
The second character is the body system.
The third character is the root operation.
The fourth character is the body part.
The fifth character is the approach.
The sixth character in the Medical and Surgical section is the device, while in the Administration section, it represents the substance.
The seventh character is the qualifier. Although the seventh character is a qualifier in both sections, in the Administration section it is used to indicate whether the substance is autologous or nonautologous, or to further specify the substance.
Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.