Tune in to this monthly online coding column, facilitated by AHIMA’s coding experts, to learn about challenging areas and documentation opportunities for ICD-10-CM/PCS.
Back in the days of ICD-9 coding, the encoder was pretty straightforward when it came to procedure coding. Nowadays, the encoder will help craft a PCS code that looks right but isn’t quite right. How many times have you heard a coder say, “That’s what the encoder gave me?” Did it give you that code or did you select that code? The encoder is an awesome, time-saving tool, but it depends on the selections made by the coder. Now more than ever, coders need to thoroughly understand anatomy and physiology, be able to comprehend an operative report, and be willing to research any unknown information. Remember, the PCS guidelines state that it is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions.
The endovascular repair of abdominal aortic aneurysms is one of those areas that requires a little more to ensure that the code is assigned correctly. The first five characters of the PCS code are pretty straightforward. We know that we are in the medical and surgical section. The abdominal aorta is below the diaphragm, so we therefore know the body system is lower arteries. The intent of the procedure meets the definition of the root operation: restriction (partially closing an orifice or the lumen of a tubular body part). Of course, the body part is abdominal aorta and the approach meets the definition of percutaneous. Assigning the device and qualifier is where it can get extremely confusing.
The assignment of the device character is dependent on the type of graft used by the surgeon. How does a coder know if an intraluminal device or a branched or fenestrated device was used? What does branched even mean, isn’t a bifurcation a branch? Well… no, not for the purposes of this code assignment. A branched or fenestrated graft has openings on the sides so that stents can be placed through the opening into the branch arteries of the aorta. The branch arteries are the left and right renal arteries, the superior mesenteric artery and the celiac trunk. A bifurcated stent graft is one that extends down into the two iliac arteries. A bifurcated stent graft does not have any side openings to accommodate branching to the side arteries.
It can be hard to differentiate which graft is being used because the operative reports can be very similar. Both of these graft types have a bifurcation at the bottom that extends down into the iliac arteries. Also, the surgeon will sometimes mention the gate placement and its proximity to the renal arteries. This is not to be confused with placement of a stent into the renal artery. Pay close attention to whether or not an endograft stent is being placed into the renal artery.
There are several resources that can help the coder decide which device value to use. One is the device key from the ICD-10-PCS 2018 Tables and Index. It tells use which device character to use based on the manufacturer.
For example, see the figure below:
This can be an easy call when the physician uses one graft. What about when the physician pieces together multiple parts to create a device for the patient? The different parts from different manufacturers can lead to different entries in the device key. Figuring out which device value to use will require the coder to fully understand the operative report. Was the stent graft placed into the renal arteries or superior mesenteric artery or the celiac trunk? If not, then it was not a branched or fenestrated graft. The coder should assign the intraluminal device value.
It should also be noted that not every vascular surgeon is approved to use a fenestrated graft. It is a good thing to know if there are any surgeons at your facility currently approved to use fenestrated grafts. If not, then know that you will not see any procedures performed with a fenestrated graft.
There are also times when a stent placement should be coded in addition to the endograft. In those instances, a stent is being placed to reopen an occluded vessel. That is a different objective and should be coded separately. Look for documentation of a stenosed or occluded vessel.
The last character of the code represents the qualifier. Many coders confuse the qualifier value “bifurcation” to mean the type of graft used. Per Coding Clinic, the qualifier value “bifurcation” is used to represent bifurcated vessels, not the type of endograft used.
Elena Miller is the director of coding audit and education at a healthcare system.