Tune in to this monthly online coding column to learn from AHIMA’s coding experts about challenging areas and documentation opportunities for ICD-10-CM/PCS.
There are a few specific guidelines associated with procedures done on the coronary arteries in ICD-10-PCS which need to be reviewed.
Coronary arteries are classified by number of distinct sites treated, rather than number of coronary arteries or anatomic name of a coronary artery (e.g., left anterior descending). Coronary artery bypass procedures are coded differently than other bypass procedures as described in the previous guideline. Rather than identifying the body part bypassed from, the body part identifies the number of coronary artery sites bypassed to, and the qualifier specifies the vessel bypassed from.
Example: Aortocoronary artery bypass of one site on the left anterior descending coronary artery and one site on the obtuse marginal coronary artery is classified in the body part axis of classification as two coronary artery sites and the qualifier specifies the aorta as the body part bypassed from.
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 coronary artery bypass are coded separately.
The coronary arteries are classified as a single body part that is further specified by number of sites treated and not by name or number of arteries. Separate body part values are used to specify the number of sites treated when the same procedure is performed on multiple sites in the coronary arteries.
Examples: Angioplasty of two distinct sites in the left anterior descending coronary artery with placement of two stents is coded as Dilation of Coronary Arteries, Two Sites, with Intraluminal Device.
Angioplasty of two distinct sites in the left anterior descending coronary artery, one with stent placed and one without, is coded separately as Dilation of Coronary Artery, One Site with Intraluminal Device, and Dilation of Coronary Artery, One Site with no device.
Now that we’ve reviewed the ICD-10-PCS guidelines relevant to procedures performed on coronary arteries, let’s look at a few case studies comparing ICD-9-CM to ICD-10-PCS.
66-year-old with severe CAD is admitted for CABG x 3 using the left internal mammary artery (LIMA) to the left anterior descending (LAD), radial artery free graft from aorta to diagonal branch, and saphenous vein graft (SVG) from the aorta to the right coronary artery (RCA). A segment of the left greater saphenous vein was harvested endoscopically and a portion of the right radial artery has harvested with an open excision. The patient was placed on cardiopulmonary bypass for this procedure.
Rationale: Both ICD-9-CM and ICD-10-PCS require a distinct code for the LIMA bypass. The aorto-coronary bypasses are coded differently in ICD-9-CM vs. ICD-10-PCS with ICD-10-PCS requiring separate codes for the different types of devices (i.e., autologous artery, autologous vein). The cardiopulmonary bypass is coded similarly in both code sets. ICD-10-PCS also requires separate codes for the harvesting of the bypass grafts, which are coded with the root operation Excision since only a portion of the artery/vein was removed.
Patient with CAD is admitted for PTCA and stenting of 3 coronary arteries. Drug-eluting stents were placed in the RCA x 2 and LAD.
Rationale: This procedure is coded very differently in ICD-9-CM and ICD-10-PCS. ICD-9-CM requires separate codes for the PTCA, insertion of stents, number of stents, and how many vessels are treated. ICD-10-PCS has one comprehensive code that describes the number of sites treated (not vessels) with PTCA and the type of stent used. If different devices (drug-eluting, non-drug-eluting, radioactive, or no stent) are used in one procedure, separate codes are assigned to indicate how many vessels are treated with that type of device.
CMS. 2015 Code Tables and Index. http://cms.hhs.gov/Medicare/Coding/ICD10/2015-ICD-10-PCS-and-GEMs.html.
CMS. 2015 Official ICD-10-PCS Coding Guidelines. http://cms.hhs.gov/Medicare/Coding/ICD10/Downloads/2015-PCS-guidelines.pdf.