With fewer than 78 days until ICD-10-CM/PCS implementation, plenty of questions still remain about ICD-10-PCS coding. The AHA’s Coding Clinic for ICD-10 continues to provide updates and guidance for a variety of inpatient procedures, both routine and not so routine. We examine some of that guidance in this article.
Lysis of adhesions
When considering what root operation to assign to a significant lysis of adhesions, coders are challenged by some of the ICD-10-PCS root operation definitions, especially if there is no evidence that the function of a body part is impaired by the adhesions.
Even though the ICD-10-PCS Index classifies adhesiolysis as a Release, ICD-10-PCS root operations may be determined without referring to the ICD-10-PCS Index. A significant lysis of adhesions could potentially fall under two different ICD-10-PCS root operations:
- Release: Freeing a body part from an abnormal physical constraint by cutting or by use of force
- Division: Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part
Getting this right is important in the performance of operations such as “re-do” open heart procedures, which can require up to an hour to perform a lysis of adhesions before reaching the operative site, says James S. Kennedy, MD, CCS, CDIP, president and chief medical officer of CDIMD-Physician Champions in Smyrna, Tennessee.
Approximately 15%-20% of patients undergoing an open heart procedure have adhesions, and almost all patients undergoing reoperations have them, according to Synthemed, Inc.
ICD-10-PCS guideline B3.14 provides some help by stating:
- If the sole objective of the procedure is freeing a body part without cutting the body part, the root operation is Release. If the sole objective of the procedure is separating or transecting a body part, the root operation is Division.
The ICD-10-PCS Reference Manual adds some addition information by stating:
Some of the restraining tissue may be taken out, but none of the body part is taken out.
Examples: Adhesiolysis, carpal tunnel release
Consider what the physician is actually doing during the lysis of adhesions. “One may ask, ‘Is the heart or pericardium physically constrained?’ ” Kennedy says.
In the root operation Release, the body part value coded is the body part being freed and not the tissue being manipulated or cut to free the body part.
Coders need to carefully review the entire operative report, not just the title, to determine the clinical significance of the adhesions and the complexity of the lysis of adhesions, Kennedy says, adding that coders should not code lysis of adhesions just because the physician documented adhesions or lysis in an operative report.
The surgeon must determine whether the adhesions and the lysis are significant enough to code and report, according to Coding Clinic for ICD-10, First Quarter 2014, p. 4. “If this is not clear, then a query is warranted,” Kennedy says.
This Coding Clinic advice deals with a situation where an obstruction is not present but a strong band prevents the surgeon from access to the organ (being removed), requiring lysis before the operation can proceed. Coders should report both the diagnosis of adhesions and the lysis procedure, unless instructional notes in the Alphabetical Index, Tabular List, or guidelines preclude the separate coding. However, if adhesions exist without causing any symptoms in the patient or increasing the difficulty of performing the operative procedure, then coders should not report a diagnosis or procedure code.
ICD-10-PCS requires documentation of what is being freed, Kennedy says. For the heart, body part choices include:
- Right atrium
- Left atrium
- Right ventricle
- Left ventricle
- Pericardium
“Note there’s no listing for ‘heart NOS,’ ” Kennedy says. Physicians must document the operative anatomy being freed. “Since ICD-10-PCS requires or allows for additional specificity, a query is required if the physician only documents that lysis of adhesions provides access to the heart.” Physicians don’t always know when to document a lysis of adhesions. Sometimes they think that lysis of adhesions is integral to a procedure, so physician education is vital, Kennedy says.
Repair of pseudoaneurysm
A pseudoaneurysm is a hematoma adjacent to a hole or other disruption of the arterial wall. “Pseudo” in Greek means false. An aneurysm is a balloon-like bulge in an artery. So instead of the pseudoaneurysm being a bulge in an artery, the blood is actually collecting outside the arterial wall.
A pseudoaneurysm is caused by blood slowly leaking into the surrounding tissue. This condition can happen pretty much anywhere in the body, says Anita Rapier, RHIT, CCS, senior coding consultant for the AHA in Chicago. Pseudoaneurysms can also occur in the heart after damage from a heart attack causes blood to leak and pool outside the injured heart muscle.
A cutdown and suturing of a pseudoaneurysm is coded using the root operation Repair (restoring, to the extent possible, a body part to its normal anatomic structure and function), Rapier says. Coders should use this root operation only when the method to accomplish the repair is not one of the other root operations, she adds.
Coding Clinic for ICD-10, First Quarter 2014, pp. 21-22, reviews two different cases involving pseudoaneurysms.
In the first, a patient is seen for an open repair of a femoral artery pseudoaneurysm via suturing. Coders should report ICD-10-PCS code 04QK0ZZ (Repair right femoral artery, open approach).
In the second case, a patient presents with a pseudoaneurysm as a complication of a previously placed right femoral popliteal bypass graft. The physician places a stent graft inside of the existing graft to reinforce it and prevent recurrence of the rupture.
Coders must assign two codes for this case, Rapier says:
- 04WY37Z, Revision of autologous tissue substitute in lower artery, percutaneous approach
- 04UK3JZ, Supplement right femoral artery with synthetic substitute, percutaneous approach
Repair of postoperative bleed
Coding Clinic has also addressed control of post-operative bleeding. ICD-10-PCS Official Guidelines for Coding and Reporting (B3.7) define the root operation Control as “stopping, or attempting to stop, postprocedural bleeding.” The guideline specifically states:
If an attempt to stop postprocedural bleeding is initially unsuccessful, and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded instead of Control.
For example, a patient suffers post-procedural bleeding and the surgeon is unable to control the bleeding. The surgeon must perform a splenectomy to stop the bleeding. In this case, coders would use root operation Resection not Control, Rapier says.
Control is used to report a small range of procedures performed to treat hemorrhaging following surgery, Rapier says. Control can include other repairs, such as ligation of a bleeder, evacuation of a hematoma, or cauterization. When these methods are used, coders should only report a Control procedure, Rapier says.
Consider this scenario. A patient undergoes a right brachial saphenous vein bypass and develops post-operative bleeding. The surgeon must return the patient to the operating room (OR) to stop the hemorrhage. In the OR, the surgeon evacuated fresh blood and a hematoma from the bypass wound.
In this case, coders would use root operation Control because the surgeon performed the procedure to control a post-operative hemorrhage, Rapier says.
Respiratory ventilation
The majority of procedures fall under the Medical and Surgical section, but Coding Clinic did address patients on ventilators in its Fourth Quarter 2014 issue.
Codes for respiratory ventilation are found in section 5 of the ICD-10-PCS Manual, Extracorporeal Assistance and Performance. As in ICD-9-CM Volume 3, these codes are based on the time the patient receives ventilator assistance. ICD-10-PCS increases the specificity of the time to:
- Less than 24 consecutive hours (fifth character 3)
- 24-96 consecutive hours (fifth character 4)
- Greater than 96 consecutive hours (fifth character 5)
Coders also need to count hours, not days, Kennedy adds. Two days does not necessarily equal 24 hours or more, just as four days does not necessarily equal more than 96 hours. “Note that the code 5A1955Z is ‘greater than 96’ hours,” Kennedy says.
The ICD-10-PCS codes for ventilation also specify the type of ventilation:
- Continuous positive airway pressure (seventh character 7)
- Intermittent positive airway pressure (seventh character 8)
- Continuous negative airway pressure (seventh character 9)
- Intermittent negative airway pressure (seventh character B)
- No qualifier (seventh character Z)
The counting of hours starts with one of the following:
- Endotracheal intubation (and subsequent initiation of mechanical ventilation)
- Initiation of mechanical ventilation through a tracheostomy
- Admission of a previously intubated patient or a patient with a tracheostomy who is on mechanical ventilation
Ventilator support provided to a patient during a surgery is considered an integral part of the surgical procedure and is not coded separately, says Sharme Brodie, RN, CCDS, CDI education specialist for HCPro, a division of BLR, in Danvers, Massachusetts.
If, however, the patient remains on mechanical ventilation for an extended period (several days) postsurgery, the mechanical ventilation should be reported. The removal and immediate replacement of an endotracheal tube (for example, in situations involving mechanical problems such as leaking of the cuff) should be counted as part of the initial duration, Brodie says.
Review the entire medical record, especially the respiratory therapy notes. Unlike diagnoses, procedure coding can be based on non-provider documentation, Kennedy says.
When a patient is being weaned from mechanical ventilation, coders should count the entire duration of the weaning process, Brodie says. This process may take several attempts and includes the:
- Time a patient is on the ventilator
- Actual weaning
- Ending (when the patient is extubated and the mechanical ventilation is turned off)
Not all patients require a weaning period, and there are times, depending on the weaning method, that the mechanical ventilator is not in use but is still considered part of the weaning process, Brodie says.
Internal facility policies cannot be used to extend the weaning process, according to Coding Clinic. Once mechanical ventilation is shut off, do not continue to count ventilator hours, even if the patient is continuously being monitored per facility protocol.
Continuous positive airway pressure delivered via a tracheostomy and bi-level positive airway pressure delivered through an endotracheal tube or tracheostomy should be coded as mechanical ventilation, according to Coding Clinic, Fourth Quarter 2014, pp. 8-9.
Editor’s note: This article was originally published in the July issue of Briefings on Coding Compliance Strategies. Email your questions to associate product manager Michelle A. Leppert, CPC, at mleppert@hcpro.com.