Coronary artery bypass graft (CABG) procedures are not the only ones coders will report using the root operation Bypass in ICD-10-PCS. Surgeons can create bypasses in other vessels of the body.
The coding rules for a CABG procedure differ somewhat from other vessel bypass procedures, says Lisa Crow, MBA, RHIA, AHIMA-approved ICD-10-CM/PCS trainer and director of auditing services for TrustHCS in Springfield, Missouri.
In a CABG, the surgeon uses a graft (often from the patient) to connect two arteries and divert the blood flow around the blockage or narrowing caused by coronary artery disease (CAD). Alternately, the surgeon may reroute the internal mammary artery around the blockage. In ICD-10-PCS codes for CABG, the fourth character (body part) specifies the body part bypassed to and the seventh character (qualifier) identifies the body part bypassed from.
For non-coronary vessels, those definitions will switch, says Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer and senior regulatory specialist and Boot Camp instructor for HCPro, a division of BLR, in Danvers, Massachusetts. The fourth character becomes the body part bypassed from and the seventh character represents the body part bypassed to.
“This is going to be really confusing for coders in the beginning depending on how many of these procedures they code,” Avery says.
Coding professionals will need to stop and think about where they are in the body so they can keep the meanings of the fourth and seventh characters straight. “You have to stop sometimes and think, ‘What are my anatomical markers?’ ” Avery says.
Anatomy in the forefront
Coding professionals will need to brush up on their anatomy and physiology to apply the body part and qualifier appropriately, says Crow. A strong foundation in anatomy will also help coding professionals locate the additional details they need to build the ICD-10-PCS code when they read the operative report.
“They should really focus on the anatomy of the vessels and the flow for all tubular body parts that could be bypassed, such as the femoral, popliteal, iliac, brachial, axillary, and innominate,” Crow says.
For arteriovenous fistulas created for dialysis patients, coding professionals will need to understand the anatomy and flow of blood. A key factor to remember is that the blood flows from the artery to the vein, and the purpose of the graft is to reinforce the vein and make it stronger to handle the dialysis.
Coding professionals will need to know the specific types of grafting material in order to assign the correct device character, Crow says.
Reasons for a peripheral vessel bypass
In many cases, patients need a peripheral artery bypass because they have peripheral artery disease (PAD), similar to patients who need a CABG because of CAD, Avery says. “These can be life-threatening situations, because the patients are losing blood flow in their lower extremities.”
Of the two situations, a coronary occlusion or stenosis is more life-threatening because patients don’t function well if the heart is not receiving adequate blood flow. In contrast, a peripheral occlusion may result in the patient losing a limb, for example a lower leg. Patients can live without the limb, but their quality of life decreases, Avery says.
The surgeon may perform a femoral-popliteal bypass to go around a blockage caused by PAD. In addition, the physician may perform a peripheral bypass for a patient who has suffered a crushing injury, says Avery.
In some cases, the physician may need to perform a peripheral bypass because of a failed implant. For example, a patient undergoes a total knee replacement, but the knee implant fractures the femur. The physician performs an internal fixation and accidentally punctures one of the major vessels in the leg. The physician may need to perform a bypass to reroute blood flow around the damaged portion of the vessel, Avery says.
Gastric bypass
For gastric bypass, coding professionals will follow the same guidelines they use for peripheral artery bypass. The fourth character will be where the bypass starts and the seventh will represent where the bypass ends.
Table 0D1 (Bypass of the gastrointestinal system) lists numerous possible body part (fourth) characters that may be used for a bypass. A bypass that begins at the stomach (fourth character 6) can end at:
- Cutaneous (4)
- Duodenum (9)
- Jejunum (A)
- Ileum (B)
- Transverse colon (L)
The bypass procedure follows the route down the GI tract. So even though the surgeon can perform a bypass that begins in the jejunum, it won’t end up in the stomach, and table 0D1 does not include stomach as a possible seventh character for a bypass that begins in the jejunum.
Having a picture of the procedure may also help, Avery says. “I’m a visual person, so it helps me to look at the picture and say, ‘Okay, we did a gastric bypass. We started in the stomach, where did we go to?’ ”
More information in codes
In ICD-9-CM Volume 3, all peripheral vessel bypass procedures are reported with a single code, 39.29 (other peripheral shunt or bypass), Avery says. “The ICD-9 codes are very generic. They don’t give you a lot of information.”
Code 39.29 encompasses multiple peripheral bypass procedures, such as femoral-popliteal, popliteal-popliteal, and axillary-brachial. That single code doesn’t even allow coding professionals to report what part of the body the bypass is in.
“We’re losing so much information in ICD-9” that can be captured in ICD-10-PCS, Avery says. “The Volume 3 code doesn’t really give me any detail whatsoever.”
By contrast, in ICD-10-PCS, if a surgeon performs a femoral-popliteal bypass, coding professionals will be able to show that the bypass went from the femoral artery to the popliteal artery, Avery says. In addition, ICD-10-PCS will allow coding professionals to report the type of grafting material the surgeon used.
For a bypass of an upper arm artery, coding professionals have the following choices for grafting material in ICD-10-PCS:
- Autologous venous tissue (9)
- Autologous arterial tissue (A)
- Synthetic substitute (J)
- Nonautologous tissue substitute (K)
- No device (Z)
“We’re going to know whether we used the patient’s own vessel or a synthetic substitute,” Avery says.
The choice of grafting material may depend on the reason for the bypass. If a patient suffers from PAD, the surgeon may decide to take a healthy piece of another vessel and bypass the diseased vessel. The vessel used in the bypass could develop PAD in the future. However, if the patient suffered a crushing injury and his or her own vessels are destroyed, the surgeon may need to use a synthetic substitute. The patient could reject the graft, or the graft could fail.
The additional specificity in ICD-10-PCS will allow coding professionals to identify whether the surgeon used any grafting material or simply used the existing vessel to bypass the disease. The ICD-10-PCS codes will also show whether the surgeon simply removed the diseased portion of the vessel and joined the ends back together, Avery says. “That’s the kind of information we need, and we’ll get it in PCS.”
This information will allow medical professionals to track how well patients do with certain substitutes. It will also better reflect the patient’s severity of illness. Coding professionals can show the exact anatomical location where the surgeon performed the bypass.
For example, in a patient with PAD, the surgeon may perform a femoral-popliteal bypass on the left leg. The ICD-10-PCS code will reflect that laterality. If the patient then comes back in six months for another femoral-popliteal bypass, coding professionals can show whether the new bypass is in the left leg, indicating a problem with the old graft, or in the right leg, showing disease progression, explains Avery.
With the lack of specificity in the ICD-9-CM Volume 3 code, none of that information is captured; the code does not reflect even a general anatomical location such as upper or lower vessels.
Preparing for ICD-10-PCS
With ICD-10-PCS, coding professionals will go from a very generic coding system to a much more detailed one. Coding professionals are going to have to look for more details when reading operative reports, especially when they first start using ICD-10-PCS, Avery says.
Start talking with physicians now about the increased level of specificity that coding professionals will need in ICD-10-PCS. The physicians may not be aware of the additional details needed, Crow says. “It may be one word that needs to be documented by the physician that would add the specificity needed to assign an accurate code,” she says. “It is important to remember that documentation is needed to assign all seven characters of the PCS code. We do not have unspecified codes in ICD-10-PCS.”
For example, the physician may document the iliac artery as the starting point for a bypass. However, ICD-10-PCS includes body part characters for the common, internal, and external iliac arteries. Coding professionals can’t guess which one the physician meant.
“Left and right is fairly easy to deduct based on the anatomy,” Crow says. “I am not sure that level of detail of internal and external will be easy for the coders to figure out.” This is a good example of adding one word, either internal or external, that would provide the specification needed for the code assignment. Alternately, coding professionals and physicians can conduct educational sessions where the physician explains what he or she is doing in a certain procedure, Crow adds. “That may make it clearer to the coders who may not have that in-depth understanding of what a procedure entails.”
Coding professionals can also look for procedure descriptions and videos online, as long as they are careful to review information from reputable sites, Crow says. Large organizations, such as Mayo Clinic, Cleveland Clinic, and some of the American College specialty sites, post videos of various procedures..
Be on the lookout for additional guidance because currently, very little guidance has been published, especially about grafting materials, Avery says. While physicians generally document these procedures well, she says, they may not spell out the material used. “If the coder is looking for the physician to come right out and say, ‘I used an autologous graft,’ they may not do that.”
If the physician does use an autologous graft, coding professionals will need to report a separate code for harvest of the vessel used in the bypass, Crow says. Currently in ICD-9-CM, coding professionals do not report the harvest procedure. It is considered integral to the bypass procedure.
The Bypass section is very detailed with the body part and device characters, Crow says. “Coders need to understand what is coming from where, where is it going to, and what is the material.”
Editor’s note: This article was originally published in the January issue of Briefings on Coding Compliance Strategies.Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.