As the largest outsource coding provider in the country we have identified trends and gained unique insights from our coders throughout the transition to ICD-10. We are sharing these insights with the broader HIM Community through our bi-weekly blog series "ICD-10 Quick Tips."
The subject matter for this series is currated based on the trending topics in our online question and answer system which services over 1,200 of our HIM professionals. Our Subject Matter Experts have an average of 20 years of experience and are considered leaders in their field.
This week's post comes from National Compliance and Quality Audit Manager, Melissa McLeod, CDIP, CCDS, CCS, CPC, CPC-1, and AHIMA Approved ICD-10 Trainer.
Well everyone, here is another one of those ‘ughhhh’ topics! Just like spinal fusions, coding of aneurysm repairs can be uniquely challenging as we are faced with a number of root operations that although all ‘sound’ as if they are applicable (occlusion, restriction, supplement, repair, replacement), not all can apply. OK, so let’s go to the ICD-10-PCS Coding Guidelines for direction…ummmm…not a lot of help there! In ICD-10-PCS, the coder must remember to identify the root operation that describes the main objective of the procedure. Let me try to clear up some of the questions you may have relating to coding these types of procedures.
Some basic information first, which is essential for accurate coding, but before you continue reading this blog I want to you all to write down the definition as you understand it of an aneurysm and a pseudoaneurysm, then put it aside for now; we will get to it later.
Done? Ok, let's continue!
The aorta is the largest blood vessel in the body and it carries blood away from the heart to the rest of the body. An aneurysm is the bulging or ballooning of a weakened area of a blood vessel. The wall of the aorta can become weak due to age, disease, or trauma and this may cause the aortic wall to bulge, leading to an AAA. As the bulge grows, the wall of the aorta becomes weaker. This may cause the aorta to rupture and lead to massive internal bleeding.
Most aneurysms show no symptoms, although some patients may be aware of abnormal pulsation in the mid-abdomen. A rapidly growing aneurysm that may soon rupture can cause pain in the back or abdominal region, sometimes with bloating or nausea and vomiting. If the aneurysm ruptures, a person will show the sudden signs of shock due to excessive bleeding such as dizziness or fainting with weakness, sweating, rapid heartbeat, and loss of consciousness. Ruptured aneurysms annually kill more than 15,000 Americans and are the 13th leading cause of death in the United States. (1)
In this treatment option, the doctor repairs the aorta by making a large cut in the abdomen. The aneurysm section of the aorta is removed and replaced with a fabric graft. The fabric graft is sewn into place and acts as a replacement blood vessel. The blood flow through the aorta is stopped while the graft is put in place. In this case: Root operation – Replacement
This is the more common way to approach AAA repairs. A stent graft is slowly released from the catheter into the aorta. As the stent graft is released, it expands to its proper size so that it snugly fits into the aorta both above and below the aneurysm. A stent graft (such as the abdominal stent graft) is placed inside the aneurysm without surgically opening the tissue surrounding it and is a fabric tube supported by a metal framework. The catheter is then removed from the body and the stent graft remains inside the aorta permanently. Additional stent grafts may be required to completely exclude the aneurysm.
What is the root operation? This can be a confusing concept and dictates that we need to focus on the intent or objective of the root operation. Supplement or restriction? In this case: Root operation - Restriction
Per Coding Clinic 1st quarter 2014, “Endovascular stent grafting involves the placement of a tubular device into the lumen of the vessel, and is designed to restrict the aneurysm. After being placed, the stent graft expands, relieving pressure on the aneurysm, and reducing the possibility of aneurysmal rupture. In ICD-10-PCS, if the aneurysm is repaired by putting a synthetic graft, stent, or other device in the lumen of the artery, the root operation is “Restriction,” and the device is “Intraluminal device.” The objective of the abdominal aortic aneurysm repair is to restrict the lumen of the vessel.”
A pseudoaneurysm is a hematoma adjacent to a hole or other disruption of the arterial wall. “Pseudo” in Greek means false. An aneurysm is a balloon-like bulge in an artery…so instead of the pseudoaneurysm being a bulge in an artery, the blood is actually collecting outside the arterial wall. A pseudoaneurysm is caused by blood slowly leaking into the surrounding tissue and can also occur in the heart after damage from a heart attack causes blood to leak and pool outside the injured heart muscle. A cutdown and suturing of a pseudoaneurysm is coded to what root operation? In this case: Root Operation - Repair (restoring, to the extent possible, a body part to its normal anatomic structure and function). Coders should use this root operation only when the method to accomplish the repair is not one of the other root operations.
Coding Clinic for ICD-10, 1st Quarter 2014, pp. 21-22, reviews two different cases involving pseudoaneurysms. In the first, a patient is seen for an open repair of a femoral artery pseudoaneurysm via suturing.
Coders should report one code for this case:
- 04QK0ZZ (Repair right femoral artery, open approach).
In the second case, a patient presents with a pseudoaneurysm as a complication of a previously placed right femoral popliteal bypass graft. The physician places a stent graft inside of the existing graft to reinforce it and prevent recurrence of the rupture.
Coders must assign two codes for this case:
- 04WY37Z, Revision of autologous tissue substitute in lower artery, percutaneous approach
- 04UK3JZ, Supplement right femoral artery with synthetic substitute, percutaneous approach
Take a look at the definitions of aneurysm and pseudoaneurysm that you wrote down…how did you go? There is a lot more I could write about regarding this topic but I will have to save that for another Blog… hopefully I was able to shed some light for you. Happy coding!