By Cindy Basham, MHA, MSCCS, BSN, CCS, CPC
ICD-10-PCS is a complex system that requires a better understanding of anatomy and physiology and surgical procedure technique compared to ICD-9-CM, Volume 3. This requirement is one of the reasons why many experienced coders may shy away from learning the fundamentals of ICD-10-PCS coding.
In order to master this complex coding system, coders need to build their foundation of knowledge by having a deep understanding of root operations.
The ICD-10-PCS coding guidelines direct the coder to understand the objective of the procedure, which will assist in the selection of the correct root operation. The guidelines further state “it is not the responsibility of the physician to alter their documentation.” Thus, the lines of communication between coders and physicians must be clear, open, and direct.
Cardiovascular procedure coding is complex, requiring extensive knowledge of anatomy as well as the objective of the procedure. Let’s begin at the guidelines specific for cardiovascular procedure coding, then discuss the root operations (objective) that are common with cardiovascular procedures.
Unique to the ICD-10-PCS coding system is the development of procedure guidelines. The following are guidelines specific to cardiovascular procedure coding:
ICD-10-PCS guideline B3.6a: Bypass procedures are coded by identifying the body part bypassed “from” and the body part bypassed “to.” The fourth character body part specifies the body part bypassed from, and the qualifier (seventh character) specifies the body part bypassed to. This guidelines applies to all bypass procedures except the coronary arteries.
- Example: Bypass from femoral artery to the popliteal artery. The femoral artery would be identified with the body part character (four) and the popliteal artery would be identified with the qualifier character (seventh).
ICD-10-PCS guideline B3.6b: Coronary arteries are classified by the number of distinct sites treated, rather than the number of coronary arteries or anatomic name of the coronary artery. Coronary artery bypass procedures are coded differently than other bypass procedures such as those mentioned in guideline B3.6a. The body part (fourth) character identifies the number of coronary artery sites bypassed to and the qualifier (seventh) character identifies the vessel bypassed from.
- Example: Aortocoronary artery bypass of one site on the left anterior descending artery. The body part (fourth) character specifies one coronary artery site and the qualifier (seventh) character specifies the aorta as the vessel bypassed from.
ICD-10-PCS guideline B3.6c: If multiple coronary artery sites are bypassed, a separate procedure is coded for each coronary artery site that uses a different device and/or qualifier.
- Example: Aortocoronary artery bypass and internal mammary artery bypass are coded separately. This is due to the different qualifier seventh character.
ICD-10-PCS guideline B3.9: If an autograft is obtained from a different body part in order to complete the objective of the procedure, a separate procedure is coded.
- Example: Aortocoronary artery bypass using the greater saphenous vein as the graft. The graft would be captured with an additional procedure code with the root operation of Excision.
ICD-10-PCS guideline B4.4: The coronary arteries are classified as a single body part that is further specified by the number of sites treated and not by the name of the coronary artery or number of arteries. Separate body part values (fourth character) are used to identify the number of sites are treated when the same procedure is performed on multiple sites in the coronary arteries.
- Example: Angioplasty with stent placement of one site in the proximal region of the left anterior descending artery and an angioplasty without a stent placed to one site of the distal region of the left anterior descending artery. There would be two different codes assigned. Both codes would identify the root operation Dilation, but one procedure included an intraluminal device (device character) and the other procedure did not utilize a device.
ICD-10-PCS has 31 different root operations. While many root operations are applicable to cardiovascular procedure coding; the following root operations are most common to cardiovascular procedures:
- Bypass: Most commonly used for coronary artery bypass surgeries (CABG).
- Destruction: Used mostly for cardiac ablation procedures to treat cardiac arrhythmias.
- Map: Used mostly during electrophysiology studies (EPS) of the electrical conduction pathway of the heart.
- Dilation: Used to identify whether the procedure objective is to dilate or open the lumen of a vessel such as percutaneous transluminal coronary angioplasty (PTCA).
- Insertion: This root operation involves the use of a device. The most common cardiovascular procedures include pacemakers, cardioverter-defibrillators, and cardiac resynchronization devices. Similar to ICD-9-CM, ICD-10-PCS requires a code for the placement of the generator as well as insertion of the electrodes (leads).
- Removal: This root operation objective is to remove the device. For example, to correctly identify a pulse generator change of a pacemaker, the coder would assign a procedure code to identify the removal of the pacemaker generator and a separate code to identify the insertion of the pacemaker generator.
- Measurement: This root operation is the choice when coding for cardiac catheterization procedures; right, left, or right and left. The additional procedures done during a cardiac catheterization such as coronary angiography and left ventriculography are coded separately from the Imaging section of ICD-10-PCS.
- Replacement: Use of this root operation is necessary for valve replacement surgeries including aortic, mitral, and pulmonary valves. The device (sixth) character will identify the type of graft such as autologous tissue substitute and non-autologous tissue substitute.
- Performance: For cardiovascular procedures such as CABGs, this root operation captures the use of the cardiopulmonary bypass.
- Supplement: Often this root operation is difficult to apply but in the cardiovascular valve procedures such as a mitral valve annuloplasty, this root operation captures the objective to supplement.
This only summarizes the complexity of cardiovascular coding in ICD-10-PCS. However, a focused review of the tables will provide additional insight into this complex system and information required for correct procedure code assignment. Continue learning about the objective of the procedure as this will assist in selecting the correct root operation.
Finally, to complete the development of a strong cardiovascular coding foundation, continue to discuss and work with the cardiothoracic surgeons about documentation requirements and to learn more about cardiovascular procedures.
Email your questions to editor Steven Andrews at sandrews@hcpro.com.