A patient with congenital hydrocephalus with a ventriculoperitoneal shunt is admitted due to shunt failure. The surgeon removes and replaces the distal end of the shunt. Which ICD-10-PCS root operation should coders use to report the procedure?
When determining the root operation, coders first need to determine the intent of the procedure, says Gretchen Young-Charles, RHIA, senior coding consultant for the American Hospital Association (AHA) in Chicago. A ventriculoperitoneal shunt drains extra fluid form the brain into the peritoneal cavity, where the fluid is absorbed.
The shunt has three basic parts:
- Ventricular catheter
- Shunt valve
- Distal catheter
The surgeon inserts the ventricular catheter into the fluid part of the brain. Fluid drains from the catheter into the valve. The valve controls the rate of flow into the distal catheter.
The shunt itself is not classified as a drainage device. It is initially placed to reroute the contents of the cerebral ventricle to another location. Coders will use the root operation Bypass (altering the route of passage of the contents of a tubular body part) for the initial placement of the shunt, Young-Charles says.
They will use “synthetic substance” as the device character for the initial procedure.
When the patient returns because the shunt is malfunctioning, coders will use root operation Revision (correcting, to the extent possible, a malfunctioning or displaced device). The codes for the revision would be:
- 0WWG4JZ, Revision of synthetic substitute in peritoneal cavity, percutaneous endoscopic approach
- 0JWS0JZ, Revision of synthetic substitute in head and neck subcutaneous tissue and fascia, open approach
For more information see Coding Clinic, Second Quarter 2015, pp. 9?10.
Always require a device
Six ICD-10-PCS root operations always require a device, says Anita Rapier, RHIT, CCS, senior coding consultant for AHA.
One of those is Revision (fourth character W). The others are:
- Change, taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane
- Insertion, 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
- Removal, taking out or off a device from a body part
- Replacement, putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part
- Supplement, putting in or on biologic or synthetic material that physically reinforces and/or augments the function of a portion of a body part
ICD-10-PCS includes four basic categories of device values:
- Grafts and prostheses
- Implants
- Simple or mechanical appliances
- Electronic appliances
Devices in the Medical and Surgical section include:
- Biological or synthetic material that takes the place of all or a portion of a body
- Biological or synthetic material that assists or prevents a physiologic function
- Therapeutic material that is not absorbed by, eliminated by, or incorporated into a body part and has the potential to be removed
- Mechanical or electrical appliances used to assist, monitor, take the place of, or prevent a physiologic function
Examples of medical and surgical devices include autografts, tissue substitutes, and radioactive elements.
Revision
Revision can include correcting a malfunctioning device by taking out and/or putting in part of the device, Rapier says.
For example, a physician may need to adjust the position of a patient’s pacemaker lead. Coders would report that procedure as a Revision.
Coders will also report Revision if a portion or component of an orthopedic implant needs to be adjusted.
Revision usually involves a component of the device and the procedure can be completed without removing the entire device, Rapier says.
Coders should never assign Z (no device) as the qualifier for a Revision, Rapier says.
Other Revision procedures include:
- Open revision of right hip replacement, involving recementing of a prosthesis
- Revision of a vascular access device reservoir placement in the chest wall, causing patient discomfort
Coders needs to be very careful because physician documentation can be misleading, Rapier says. The physician may use the term revision for a procedure that does not meet the ICD-10-PCS definition of Revision. Coders need to select the root operation that best describes the procedure the physician actually performed, not what the physician called it. For more information, review ICD-10-PCS guideline A11.
Revision of femoropopliteal bypass graft
A patient with a femoropopliteal bypass graft comes in because the graft has become occluded. The physician performs an open thrombectomy with trimming and reanastomosis of the existing graft.
Coders would report 04WY07Z (Revision of autologous tissue substitute in lower artery, open approach).
“Because the work was done on an existing graft, you would use root operation Revision,” Rapier says.
Replacement
Coders will use ICD-10-PCS root operation Replacement when the physician removes a body part and replaces it with a device. The body part may have been taken out or replaced, or may be taken out, physically eradicated, or rendered nonfunctional during the Replacement procedure Rapier says.
When the physician removes a device from a previous surgery, coders will also report root operation Replacement.
Examples of Replacement procedures include:
- Excision of abdominal aorta with GORE-TEX® graft replacement
- Tendon graft to right ankle using cadaver graft
- Mitral valve replacement using porcine valve
Consider a patient with an aortic aneurysm. The surgeon performs an open repair and removes the weak spot in the aorta. The surgeon then places a graft to take the place of the removed section of the aorta.
“If the aneurysm is repaired by cutting it out and putting in a graft, use root operation Replacement,” Rapier says.
Removal
In some cases a physician takes out a device and replaces it with a similar device. These procedures are coded using root operation Removal. Removal only involves removing a device.
If the physician takes out a device and puts in the new one using an external approach, use root operation Change instead of Removal, Rapier says. For example, if a physician switches out a drainage device, report Change.
Coders will report two codes for a Removal procedure. Report one code for the Removal, and a second code for putting in the new device using the root operation performed, Rapier says.
Removal encompasses a broader range of devices than those found under root operation Insertion, Rapier says.
Remember to use a general body part value when the table does not include the specific body part, she adds.
Total knee revision
A patient with painful right total knee arthroplasty presents for revision. The physician removes the old components and inserts and cements new tibial and femoral components. Coders will report two codes for this procedure: one for the removal of the old components and one for the replacement with new components, Rapier says.
According to Coding Clinic, Second Quarter 2015, pp. 18?19, coders would report:
- 0SRC0J9, Replacement of right knee joint with synthetic substitute, cemented, open approach
- 0SPC0JZ, Removal of synthetic substitute from right knee joint, open approach
Although the physician documented revision in the operative note, ICD?10?PCS defines Revision as correcting the position or function of a previously placed device without taking out and putting a whole new device in its place, Rapier says.
A complete redo of a procedure is coded to the root operation performed.
In this example, both Removal and Replacement were carried out, so coders would report those procedures, Rapier says.
Email your questions to editor Steven Andrews at sandrews@hcpro.com.