WashingtonStateHealthInformationManagementAssociationPresentedbyVirginiaBaileyRN,CCDS

MemberACDIS,FLACDIS,AHIMA,FHIMA,GCHIMAICD-10-PCS-CardiovascularProceduresDefined

March29th,2016LynnwoodConventionCenter,3711196thStSW,Lynnwood,WA

98036MedPartnersUniversity,MedPartners,TampaFL

SimpleDefinitionofCARDIOVASCULARmedical:oforrelatingtotheheartandbloodvessels

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cardiovascularadjective  car·dio·vas·cu·lar  \-ˈvas-kyə-lər\

*  Describethediseaseprocessesandanatomyinvolvedinselectedcardiacprocedures.*  Explainthecodingprocessforselectedcardiacprocedures.*  DiscussthedocumentationneedsforspecificICD-10-CM/PCSCardiaccodes*  Providecardiacprocedurecasestudyexamples

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Objectives

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*  MedPartnersUniversity(MPU)encouragesthelearnertoreviewallresourcematerialsassociatedwiththeirareaofexpertise.*  MPUdoesnotsupersedeanyofficialinformationpublishedbyACDIS,AHIMA,AHA,AMAorCMS.*  Recognizethatstateswillvary;facilitieswillvary.*  Ruleschange.*  Althoughwestriveforperfectionwedonotclaimtoalwaysbecorrect*  Readandself-educate.

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Disclaimer

*  CoronaryArteryDisease(CAD)isdefinedasablockageofoneormorearteriesthatsupplybloodtotheheartduetoatherosclerosis.*  ICD-10-CMrequirespreciseproviderdocumentationin

ordertoassignthecorrectCADcode.*  ICD-10-CMprovidesspecificcombinationcodesforCAD

withorwithoutvariousformsofanginapectoris.Theprovidermustdocumentthetypeofanginapectorisinordertoassignthecorrectcombinationcode.

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CoronaryAtherosclerosis/CoronaryArteryDisease

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*  CongenitalCAD:Q24.5*  Atherosclerosisofnativecoronaryartery(withorwithout

variousformsofanginapectoris):I25.10throughI25.119*  Atherosclerosisofunspecifiedcoronaryarterybypass

graft[s]withvariousformsofanginapectoris:I25.700throughI25.709*  Atherosclerosisofautologousveincoronaryarterybypass

graft[s]withvariousformsofanginapectoris:I25.710throughI25.719

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ExamplesICD-10-CMCADCoding

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*  Atherosclerosisofautologousarterycoronaryarterybypassgraft[s]withvariousformsofanginapectoris:I25.720throughI25.729*  Atherosclerosisofnon-autologousbiologicalcoronaryarterybypassgraft[s]withvariousformsofanginapectoris:I25.730throughI25.739*  Atherosclerosisofnativecoronaryarteryoftransplantedheartwithvariousformsofanginapectoris:I25.750throughI25.759

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ExamplesICD-10-CMCADCodingContinued

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*  Autologousveinisaveinthatoriginatesfromthepatient,suchasthesaphenousveingraftinthelegthatisusedtocreateabypassinthecoronaryartery.*  Autologousarteryisanarterythatoriginatesfromthepatient,suchasaninternalmammaryarterygraftthatisusedtocreateabypassinthecoronaryartery.*  Non-autologousbiologicalisgraftingmaterialthatdoesnotoriginatefromthepatient.

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SelectedDefinitions

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CommonAreasofCoronaryArteryBlockage

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*  CoronaryArteryBypassGraft(CABG)isasurgicalprocedureinwhichoneormoreblockedcoronaryarteriesarebypassedbyagrafttorestorenormalbloodflowtotheheartandreducetheriskofdeathfromCAD.Thisprocedureisperformedonastillheart(withtheuseofcardiopulmonarybypass)oronabeatingheart(“off-pump”bypass).

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CoronaryArteryBypassGraft(CABG)

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*  Bypassisdefinedasalteringtherouteofpassageofthecontentsofatubularbodypart.*  Abypasscanreroute(1)thecontentsofabodyparttoadownstreamareaofthenormalroute,(2)toasimilarrouteandbodypart,or(3)toanabnormalrouteanddissimilarbodypart.*  Bypassincludesoneormoreanastomoses,withorwithouttheuseofadevice.

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ICD-10-PCSRootOperation:Bypass

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*  B3.1b:“Componentsofaprocedurespecifiedintherootoperationdefinitionandexplanationarenotcodedseparately.Proceduralstepsnecessarytoreachtheoperativesiteandclosetheoperativesite,includinganastomosisofatubularbodypart,arealsonotcodedseparately.”*  Example:Thoracotomytoaccesstheoperativesitewouldnotbecodedseparately.

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ICD-10-PCSCodingGuidelinesforCoronaryBypassProcedures

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*  B3.6b:“Coronaryarteriesareclassifiedbythenumberofdistinctsitestreated,ratherthannumberofcoronaryarteriesoranatomicnameofacoronaryartery(e.g.leftanteriordescending).

*  CoronaryarterybypassproceduresarecodeddifferentlythanotherbypassproceduresasdescribedinGuidelineB3.6a.Ratherthanidentifyingthebodypartbypassedfrom,thebodypartidentifiesthenumberofcoronaryarteriesbypassedto,andthequalifierspecifiesthevesselbypassedfrom.”

*  Example:Aortocoronaryarterybypassofonesiteontheleftanteriordescendingcoronaryarteryisclassifiedinthebodypartaxisofclassification(character4)asonecoronaryarterysiteandthequalifier(character7)specifiestheaortaasthebodypartbypassedfrom.

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ICD-10-PCSCodingGuidelinesforCoronaryBypassProcedures

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*  B3.6c:“Ifmultiplecoronaryarterysitesarebypassed,aseparateprocedureiscodedforeachcoronaryarterysitethatusesadifferentdeviceand/orqualifier.”*  Example:Aortocoronaryarterybypassandinternalmammaryarterybypassarecodedseparately.

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ICD-10-PCSCodingGuidelinesforCoronaryBypassProcedures

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*  B3.9:“Ifanautograftisobtainedfromadifferentbodypartinordertocompletetheobjectiveoftheprocedure,aseparateprocedureiscoded.”*  Examples:Coronarybypasswithexcisionofsaphenousveingraft,excisionofsaphenousveiniscodedseparately.

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ICD-10-PCSCodingGuidelinesforCoronaryBypassProcedures

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*  PleasereferencetheaforementionedCodingClinicforcompleteinformation.Asummaryfollows:*  CABGusingtheleftinternalmammaryartery(LIMA)asa

pediclegraftwhereintheLIMAgraftremainedattachedandwasnotexcisedfromthepatient.Aseparatecodeshouldnotbereportedforharvesting/excisionoftheLIMA.*  InacaseoftheharvestofasaphenousveinforCABG

whereinthephysiciandoesnotdocumenttothegreatestlevelofspecificity(i.e.upper/greaterorlower/lessersaphenousvein),aqueryisneededinordertoassignthecorrectICD-10-PCScode.

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CodingClinic,ThirdQuarter2014,PageEight

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ICD-10-PCSCodeStructure

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*  TIP:Tobuildavalidcode,characters4through7mustcomefromthesamerow;youcannotselectcharactersfromdifferentrows.*  TIP:Sometables,duetotheirlength,mustbecontinuedonthenextpageinICD-10-PCScodingmanuals.Thevalueselectionmustbemadewithinthesamerowofthetable.

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PCSTableTips

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Character6-CABGDevices

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*  CardiopulmonarybypassiscommonlyusedinCABGproceduresbecauseoftherelativedifficultyofoperatingonabeatingheart.Thecodetableforthisprocedurecanbefoundinthe“ExtracorporealAssistanceandPerformance”sectionoftheICD-10-PCScodebook.“Performance”,therootoperationforcardiopulmonarybypass,isdefinedas“completelytakingoveraphysiologicalfunctionbyextracorporealmeans”.

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CardiopulmonaryBypass

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*  CABGx3–Reversesaphenousveingraftfromtheaortatotheobtusemarginalandposteriordescendingartery;leftinternalmammaryarterytotheleftanteriordescendingartery;cardiopulmonarybypass.

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CABGExample

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*  BriefDescriptionofProcedure:Rightgreatersaphenousveinwasharvestedfromlowerextremitywithpercutaneousendoscopicharvestingtechnique.Sternotomywasperformed.LeftinternalmammaryarterywastakendownwithelectrocauteryandfineHemoclips.Pericardiumwasopened.Thepatientwasplacedoncardiopulmonarybypass.TheLIMAwasdissectedasapedicle.Thesaphenousveingraftwasplacedend-to-endwiththeposteriordescendingarterythenaseparategraftwasplacedtoobtusemarginal.TheLIMAwassubsequentlyplacedend-to-sidewiththeleftanteriordescendingartery.Patientweanedfromcardiopulmonarybypass.Incisionclosedandpatientwastakentorecoveryingoodcondition

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CABGExample

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*  021109W-Coronaryarterybypass,twosites,fromaortawithautologousvenoustissue,openapproach*  02100Z9-Coronaryarterybypass,onesitefromLIMA,openapproach*  06BP4ZZ-Excisionofrightgreatersaphenousvein,percutaneousendoscopicapproach*  5A1221Z-Cardiopulmonarybypass

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CABGExample

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ICD-10-PCSCardiacInterventionCoding

DiagnosticCatheterization/PTCA

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Acardiaccatheterizationisadiagnosticprocedureusedtodetect,measure,andverifyacardiaccondition.Theproceduraltechniqueinvolvesaslightpunctureofthecommonfemoralartery(mostcommon)withinthelegandplacementofaflexiblecatheter.Usingaretrogradeapproach,thecatheterispassedintothecoronaryvessels.Once

placedinthecoronaryvessel,dyeisinjectedtotakeapictureofthevessel(angiography)

CARDIACCATHETERIZATION

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“RetrogradeApproach”

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•  Thetechniqueof“retrograde”approachisusedtoreachtheocclusionviacollateralvesselstotheaffectedvessel.

•  Technicaldefinition:Theretrogradeprocedureconsistsofcannulatingthe2coronaryostiaandadvancingaguidewirefromtheunoccludedarterytotheregiondistaltotheocclusionviacollateralsoriginatingfromthehealthyartery.

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DocumentationComparisonDiagnosticCatheterization/PTCA

ICD-9toICD10

ICD-9DocumentationNeeded:

*  Left,rightorbothsidesofheartforthecatheterization

*  Numberofstentsinserted*  Typeofstent-Drugeluting,

baremetalorboth*  Numberofcoronaryvessels

treated(ifknown)*  Angiography?Fluoroscopy?

ICD-10DocumentationNeeded:

*  Left,right,orbothsidesofheartforthecatheterization

*  Approach-percutaneousoropen*  Numberofsitestreated(NOT

numberofcoronaryvessels)treated

*  Typeofdevice(s)used*  Ifcontrastused-needthetype

High-LowOsmolarorOther.

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•  CanbeperformedontheRight,LeftorCombinedareasoftheheartviadyeinjectedintothecoronaryvessel(s)forvisualization.

•  Mayalsoincludefluoroscopicguidance,withorwithoutcontrast,whichmayormaynotbecodedseparately(PCSTableB21-facilityspecific)

•  Generallyperformedusingapercutaneousfemoral(Judkinstechnique),radialorbrachial(leastcommon)approach

DiagnosticCardiacCatheterization

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*  HeartAttack(includesSTelevationMI,Non-STElevationMI,UnstableAngina)*  AbnormalStressTest*  New-onsetunexplainedheartfailure*  Survivalofsuddencardiacdeathordangerouscardiac

arrhythmia*  Persistentchestpaindespiteoptimalmedicaltherapy*  WorkupofsuspectedPrinzmetalAngina(coronary

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IndicationsforDiagnosticCardiacCatheterization

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ICD-10-PCSclassifiescardiaccatheterizationstothe:

•  MeasurementandMonitoring-Section(Character1)•  Physiologicalsystems-BodySystem(Character2)•  Measurement-RootOperation(Character3)•  Samplingandpressure-Function/Device(character6)•  Andaqualifier(Character7)specifyingwhetheritwasaleft

heart,rightheart,orbilateralcatheterization(shownbelow)

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*  4A023N8 Measurementofcardiacsamplingandpressure,bilateral,percutaneousapproach*  4A023N6Measurementofcardiacsamplingandpressure,rightheart,percutaneousapproach*  4A020N7Measurementofcardiacsamplingandpressure,leftheart,openapproach

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Examplesofcardiaccatheterizationcodes:

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PercutaneousTransluminalCoronaryAngioplasty(PTCA)

PTCADilatesnarrowedcoronaryarteriesblockedbyplaque,called“lesions”byBalloonorstent

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*  Dilationisdefinedasexpandinganorificeorthelumenofatubularbodypart*  Mayormaynotincludetheinsertionofadevice*  ONLYappliestoaTUBULARbodypartoranOrifice

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ICD-10-PCSRootOperation:Dilation

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*  Coronaryarteriesareclassifiedasasinglebodypartthatarespecifiedbythenumberofsitestreatednotbythenameofthevessel(RCA,LAD)(RefertoPCSTable027-BodyPart-character4)*  CoronaryArtery,OneSite*  CoronaryArtery,TwoSites*  CoronaryArtery,ThreeSites*  CoronaryArtery,FourorMoreSites

*  AngioplastyproceduresperformedontwodistinctSITESinonecoronaryvesselwithplacementoftwostentsarecodedtoonecode*  Example-PTCAwithstentplacementoftwositesintheLAD.

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ICD-10-PCSGuidelineReminder

RootOperationDilation

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*  AngioplastyproceduresperformedontwodistinctSITESinonecoronaryvesselwithplacementofadrug-elutingstentandplacementofabaremetalstentiscodedseparately.*  Example-LADwithplacementofadrug-elutingstent

andnon-drug-elutingstentrequirestwocodes*  1)onecodeforthesixthcharactertocapturetheplacementofthedrug-elutingstentand*  2)onecodetocapturetheplacementofthenon-drugelutingstent.

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ICD-10-PCSGuidelineReminder

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PCSTable027fromthe2016ICD-10-PCScodebook:

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*  MakeuseofAppendixF-DeviceKey(samplebelow)andAppendixG-DeviceDefinitionsintheICD-10-PCS2016codebook

*  TeachyourphysicianstostatewhetherthestentisDrug-eluting(DES,drugcoated,medicated)orNon-drug-eluting(BareMetal)*  Keepalisthandyofthemostusedstentsinyourfacility-

havethephysicianprovideyouwiththelistandwhethertheyaredrug-elutingornot.

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TipstodeterminetheDevice

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*  Drug-eluting*  Cypher(coatedwithsirolomus)**  Endeavor(Medtronic-coatedwithzotarolimus)**  Taxus(coatedwithpaclitaxel)**  Heparin-coated*  NonDrug-eluting*  Baremetal-nocoatingorcoveringbutcanbemesh-like

tubeoverthinwire

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SomeCommonCardiacStents

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*  Thepatientcametothehospitalwithunstableangina.HewastakenemergentlytothecardiaccathlabandunderwentleftheartcathJudkinstechnique,coronaryangiography,leftventriculogramviafemoralarterypuncture.(Lowosmolarcontrastused)FindingswereneartotalocclusionoftheRCAand80%stenosisoftheleftcircumflex.DecisionwasmadetodoaPTCAandstentinsertion.TheRCAhadangioplastyreducingthestenosisto10%;adrugelutingstentwasthenplacedintheRCA.Theleftcircumflexhadangioplastywithplacementofastent.Hetoleratedtheprocedurewell.Hewasmonitoredpostoperatively.Hewasinstructedonsmokingcessationrelatedtohisnicotineaddiction,smoking2packsofcigarettesperday.Finaldiagnosisisunstableanginaduetocoronaryarteriosclerosis.Hewillfollowupintheofficeintwoweeks.

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CodingExample-PTCA

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*  –Leftheartcatheterization4A023N7*  –CoronaryangiographyB2111ZZ*  –LeftventriculogramB2151ZZ*  –PTCARCAwithdrugelutingstent027034Z*  –PTCALeftcircumflexwithplainstent02703DZ

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PCSCodes:

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Questions

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ThankYou!