By Megan DeVoe, CCS
In the June 2017 issue of the Journal of AHIMA, I wrote an article on coding Impella®/IABP External Ventricular Support and the impact on MS-DRG Assignment. Of course, as soon as I submitted the article, things changed! Welcome to the world of coding, where instruction and technology are ever evolving. I think many of us have a love/hate relationship with coding. Just when you think you might know a thing or two, along comes a modification to give you a few gray hairs. It is incredibly interesting to see new procedures and technology develop but can be challenging when the ICD-10 coding guidelines and instructions change along with them. Hopefully the ICD-10-PCS changes for FY2018 will help clear up any ambiguity for these devices
First, let’s recap the previous article where we talked about how coding professionals can confidently assign codes for both the external ventricular assistance and the Impella/IABP device insertion when the patient leaves the operating room (OR) with the device in place. The case examples in the article demonstrated how coding the Impella device insertion increased the weight of the DRG to 16.1076 from 9.644. That is a significant weight increase and low-hanging fruit for recovery auditors.
For fiscal year (FY) 2018, effective 10/01/2017, a new ICD-10-PCS qualifier of J–Intraoperative was added to table 02H, Insertion, Heart and Great Vessels, for the body part A–Heart. Along with this new qualifier value, device value R was revised FROM External Heart Assist System TO Short-term External Heart Assist System. Aren’t these interesting changes?
The ICD-10 Coordination and Maintenance Committee’s March 7, 2017 meeting notes give some rationale for this change:
”In the Heart and Great Vessels body system, revise the device value External Heart Assist System to Short-term External Heart Assist System, and add the qualifier Intraoperative to table 02H, Insertion to clarify that these are short-term devices and to distinguish between procedures in which the device is used intraoperatively only, and procedures where the device remains in the patient at the conclusion of the procedure, and is removed anywhere from several hours to several days later. In addition, add the qualifier Biventricular to tables 02P and 02W, Removal and Revision in the Heart and Great Vessels body system, for the device value External Heart Assist System, to enable precise reporting of these procedures to remove or revise a biventricular external heart assist device.”
Let’s look at the impact of these ICD-10-PCS code changes on the MS-DRGs. Since the MS-DRG grouper is not published yet, we can review version 35 of the ICD-10-CM/PCS MS-DRG Definitions Manual located on the CMS website. The new ICD-10-PCS code for the percutaneous, intraoperative placement of a short-term external ventricular heart assist device is: 02HA3RJ, Insertion of Short-term External Heart Assist System into Heart, Intraoperative, Percutaneous Approach. This ICD-10-PCS code is found in MDC 05 Diseases & Disorders of the Circulatory System, Other Heart Assist System Implant, MS-DRG 215 OTHER HEART ASSIST SYSTEM IMPLANT. This is the same MS-DRG that our previous code 02HA3RZ, Insertion of Short-term External Heart Assist System into Heart, Percutaneous Approach, fell into last year and still does for FY2018. Deciding whether to code the insertion of an external heart assist system for either purpose, intraoperative or as a short- term support measure, will no longer have the enormous impact on the MS-DRG weight since both ICD-10-PCS codes 02HA3RJ and 02HA3RZ fall into the same MS-DRG 215 OTHER HEART ASSIST SYSTEM IMPLANT.
Along with these ICD-10-PCS code and MS-DRG changes, the device guidelines have been revised with the addition of a sentence for the qualifier Intraoperative (ICD-10-PCS Official Guidelines for Coding and Reporting FY 2018, General guidelines B6.1a) and now states, “In limited root operations, the classification provides the qualifier values Temporary and Intraoperative, for specific procedures involving clinically significant devices, where the purpose of the device is to be utilized for a brief duration during the procedure or current inpatient stay.” This supports coding the insertion of devices, such as Impella, even if the device is removed at the conclusion of the procedure.
Keep your eyes peeled for a correction/clarification article from AHA’s Coding Clinic on this subject. Since there are already a few Coding Clinic articles addressing external heart assist systems, a correction/clarification would make sense. I would also encourage you to check out the ICD-10 Coordination and Maintenance Committee meetings. The meeting materials can be found on the CMS website at https://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/meetings.html, as well as information on how to attend or view a meeting. These meetings provide detailed information on many of the upcoming code changes, including descriptions of procedures, disease processes, and rationale for the requested changes.
Centers for Medicare and Medicaid Services. “ICD-10-CM/PCS MS-DRG v35.0 Definitions Manual.” https://www.cms.gov/ICD10Manual/version35-fullcode-cms/fullcode_cms/P0029.html.
Centers for Medicare and Medicaid Services. “Medical and Surgical Section Guidelines (section 0); B6 Device.” ICD-10-PCS Official Guidelines for Coding and Reporting. 2018.
Centers for Medicare and Medicaid Services. “2018 ICD-10 PCS and GEMs.” 2018 ICD-10-PCS files. https://www.cms.gov/Medicare/Coding/ICD10/2018-ICD-10-PCS-and-GEMs.html.
Megan DeVoe is senior product specialist at TruCode.