Part 2: New ICD-10 Codes and IPPS Changes
RHIA, CDIP, CCS, CCS‑P, CIRCC
Executive Director Of Education
AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador
New ICD-10-CM Codes
In Part 1 of this 4 part series we discussed some of the new ICD-10-CM diagnosis changes. In Part 2 we present the significant ICD-10-PCS procedure code changes. Here is the breakdown:
72,184 total ICD-10-CM codes for FY2020
- 324 changes all together (2019 had 473 changes)
- 273 new codes (2019 had 279 new codes)
- 21 deleted codes (2019 had 51 deleted codes)
- 30 revised codes (2019 had 143 revised codes)
Official Guidelines for Coding and Reporting ICD-10-PCS
There are several minor changes to the guidelines that include adding more descriptive terms, and adding examples. An exception was added to B3.1b Multiple Procedures in that mastectomy followed by breast reconstruction, both resection and replacement of the breast are coded separately. Likewise, in guideline B3.9 for Excision of Graft, clarification of DIEP was added: Replacement of breast with autologous deep inferior epigastric artery perforator (DIEP) flap, excision of the DIEP flap is not coded separately. The seventh character qualifier value Deep Inferior Epigastric Artery Perforator Flap in the Replacement table fully specifies the site of the autograft harvest.
A brand new Section D – Radiation Therapy has been added. This will help coders to know when to report an “Insertion” code with device value “radioactive element” in addition the modality in the radiation therapy section, and when not to. For example, brachytherapy with implantation of a low dose rate brachytherapy source left in the body at the end of the procedure is coded to the applicable treatment site in section D, Radiation Therapy, with the modality Brachytherapy, the modality qualifier value Low Dose Rate, and the applicable isotope value and qualifier value. The implantation of the brachytherapy source is coded separately to the device value “radioactive element” in the appropriate Insertion table of the Medical and Surgical section (0). The Radiation Therapy section code identifies the specific modality and isotope of the brachytherapy, and the root operation Insertion code identifies the implantation of the brachytherapy source that remains in the body at the end of the procedure. There is an exception to this for Cesdium-131 Collagen implant in that this procedure identifies both the implantation and brachytherapy, so only one code is needed. There is also guidance on placing temporary applicators for delivering brachytherapy.
Guidelines for Section E – New Technology Section (X codes) was updated to state that Section X codes fully represent the specific procedure described in the code title, and do not require additional codes from other sections of ICD-10-PCS. So all the coder needs to assign is the new technology code.
Major Changes to the ICD-10-PCS Tables
Coders will notice than there were many deleted ICD-10-PCS codes for FY2020. This is primarily because of the removal of “Bifurcation” as a qualifier in all upper and lower artery tables. However it remains as a choice for the coronary arteries. That change eliminated quite a few codes. This was a troublesome area for coders as many did not know when to assign the bifurcation qualifier.
ICD-10-PCS also removed approach “external” from all breast procedures. The index has been updated to indicate that procedures performed on the skin of the breast be coded to body part “Skin, chest” and not to breast.
In the Administration Section, body part value for peripheral or central “artery” was removed, eliminating many ICD-10-PCS codes. This was done because transfusions are done through veins, not arteries.
A device value for Internal fixation device, intramedullary limb lengthening for insertion of upper or lower bones was added. This includes the PRECICE intramedullary limb lengthening system. This would be coded to root operation “Insertion” and not “Reposition” as the surgeon is lengthening the bone, not repositioning a fracture.
A new device for Intraluminal Device, Flow Diverter for Restriction in Upper Arteries was added for the Pipeline™ and Surpass Streamline ™ Flow Diverter devices. The flow diverter, sometimes called a stent is designed to reliably open and provide consistent mesh density across the neck of the aneurysm to aid in aneurysm occlusion while maintaining perforator artery patency. Coders will need to be sure to research these types of devices that the proper device value is assigned.
A new device value for Subcutaneous Defibrillator Lead in Subcutaneous Tissue and Fascia for the S-ICD ™ lead was added. The EMBLEM S-ICD System is an innovative and truly novel ICD. Unlike traditional ICDs that require placement of at least one lead in or on the heart, the S-ICD System is implanted just under the skin and provides the patient protection from sudden cardiac arrest without invading the heart and blood vessels. It is the only fully subcutaneous (under the skin) ICD available at the current time. However coders should be on the look out for new S-ICDs.
Innominate artery, also known as the brachiocephalic artery was added as a qualifier under the Bypass root operation in the Heart and Great Vessels body system In addition, coronary arteries were added to the “Insertion” and “Supplement” root operations. Coders must be careful not to use “Insertion” and the coronary artery body part for PCI stent insertion. PCI angioplasties are still coded to root operation Dilation. The root operation for “Insertion” of device in coronary artery is for s stent insertions DURING TAVR OR VALVE REPLACEMENTS to help prevent the risk of coronary obstruction following valve insertion. So this type of stent is not really treating a condition such as CAD, it is a preventative device at time of other surgery. Supplement of coronary arteries is done to reinforce or augment coronary arteries, such as a stent graft placed to seal and reinforce a perforated/dissection of artery status post atherectomy. The objective is to supplement the wall of the artery.
Coders can not code EGD with occlusion of gastric vein as “Gastric Vein” was added as body part value for procedures done via natural or artificial opening and natural or artificial opening endoscopic.
Under Performance, Circulatory a new Duration of “Intraoperative” was added so coders could code ECMO done intraoperatively. In recent years, providers are increasingly performing short-term, percutaneous ECMO procedures in addition to open-chest ECMO. ECMO was originally only used for respiratory support, but today, ECMO is commonly used for respiratory and cardiac support. CentralECMO cannulation involves sternotomy and direct surgical cannulation of the right atrium and aorta. This involves two open insertions; arterial and venous and provides cardiorespiratory support.
V A Peripheral ECMO cannulation involves two femoral percutaneous insertions; arterial and venous. This type of ECMO support provides respiratory and circulatory support.
V V ECMO requires two venous insertions, one in the upper veins and one in the lower veins. This provides respiratory support only.
For “Other Procedures,” a new method of “Fluorescence Guided Procedure” was added. An example is a fluorescent label attached to a marker (e.g. a monoclonal antibody) that binds specifically and selectively to tumor cells, helping the surgeon ‘see’ the tumor and metastatic tissue in real time. Fluorescent markers can be used with a wide range of procedures, including classic (‘open’) surgery, laparoscopic surgery, and diagnostic procedures such as colonoscopy.
A new device for dilation of artery with sustained release drug-eluting intraluminal device was added as a New Technology X code, X27. The Eluvia and SAVAL stents are two such devices.
Another new device called a cerebral embolic filtration, single deflection filter was added to new technology table X2A. One example is the Embrella Embolic Deflector (Embrella Cardiovascular Inc, Wayne, Pa) which was designed to meet the need for embolic protection during procedures on the heart or involving the passage of catheters over the aortic arch. Emboli may arise from manipulation of the heart valves or atria and aorta and this device deflects them. There are several types of aortic arch filters that the coder must become familiar with. They include: a single filter but not a deflection filter (Embol-X)
Two single deflection filters called Embrella, TriGuard to the right. (Device 2 – Cerebral Embolic Filtration, Single Deflection Filter) and a third one called Sentinel which is a dual filter (Device 1 – Cerebral Embolic Filtration, Dual Filter)
In Part 3, the pertinent IPPS changes will be presented. In the final Part 4, New Technologies (X codes) and payment impacts will be presented and discussed in detail.
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
In Part 2 of our Sepsis Series, we are going to focus on sequencing of sepsis when the diagnosis is clearly documented. Later in the series we will look at what to do when the diagnosis is not clearly documented.
In this series, we will learn what sepsis is or causes of sepsis, how to sequence the diagnosis in ICD-10-CM, what are the clinical indicators for sepsis, is a query necessary before reporting the diagnosis of sepsis, and how to prevent denials on sepsis records.
In the previous three parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes, ICD-10-PCS procedure code changes and FY2020 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2020.
In the previous two parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes and ICD-10-PC procedure code changes. In this session we will review the major IPPS changes for FY2020. On August 2, 2019, CMS published the Final Rule for IPPS (CMS-1716) FY2020 IPPS Final Rule.
This is Part 1 of a 4 part series on the FY2020 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. There are 72,184 total ICD-10-CM codes for FY2020.
We have finished with the step-by-step coding tidbits on coding of spinal fusions. If you were not able to catch Parts 1-13 of this series focused on spinal fusions, please visit hiacode.com/topics/series/spinal-fusion-coding/.
In Part 12, we focused on intra-operative peripheral neuro monitoring used during spinal fusion surgery. In Part 13, we are going to focus on harvesting of autograft and is it coded. Remember in Part 6, we learned that autograft is bone from the patient.
In Part 11, we focused on identifying the computer assisted navigation used during spinal fusion surgery. In Part 12, we are going to focus on intra-operative peripheral neuro monitoring.
In Part 10, we focused on identifying whether or not hardware from a previous spinal fusion is coded. In Part 11, we are going to discuss computer assisted navigation.
In Part 9, we focused on identifying if decompression was also performed and if so, on which body part. In Part 10, we are going to focus on identifying if hardware was removed from a previous fusion site.
In Part 8, we focused on identifying if a discectomy was performed, and if so, if it was a partial or a total discectomy. In Part 9, we are going to focus on identifying if a decompression was performed, and if so, was it of the spinal cord, spinal nerves or both?
In Part 7, we focused on identifying any instrumentation that may be used during a spinal fusion. In Part 8, we are going to focus on identifying if a discectomy is performed and if this is an excision or a resection of the disc.
In Part 6, we focused on identifying the type of bone graft product used for the spinal fusion. In Part 7, we are going to focus on identifying any instrumentation or device used.
In Part 5, we focused on identifying the approach being used for the spinal fusion. In Part 6, we are going to focus on identifying the type of bone graft used for the spinal fusion.
In Part 4, we focused on determining the spinal column being fused. In Part 5, we are going to focus on identifying what approach is being used to complete the spinal fusion (anterior, posterior or both).
This past year, HIA implemented “Buddy Up,” a program designed to help the new hire have a smooth transition into their new HIA roles with the assistance of a “buddy.” What is a Buddy? The Buddy is simply a peer who can guide the new hire in order to make them feel more comfortable. We are very proud of this program and have many success stories that we would like to share. Take a look at the wonderful feedback we have received below.
In Part 3, we focused on determining the level of the fusion(s) and how to determine the number of vertebrae fused. In Part 4, we are going to focus on identifying which column is being fused (anterior, posterior or both).
Part 3: Spinal Fusion Coding — Determine the Level(s) or Region of Fusion and Number of Vertebrae Fused
In Part 1, we learned the diagnoses associated with the need for spinal fusions, and in Part 2 the need to identify if the fusion is an initial or refusion of the vertebrae. In Part 3, we are going to focus on determining the level(s) of fusion, as well as the number of vertebrae fused.
In Part 2, we are going to look at the differences between initial fusion and a refusion. In ICD-9, there were specific codes to show if the fusion was an initial fusion, or if it was a refusion. In ICD-10-PCS, initial fusions and refusion procedures are coded to the same root operation “fusion.”
This is Part 1 of a 14 part series focusing on education for spinal fusions. Spinal fusion coding is a tough job for coders. There are so many diseases/disorders that result in the need for spinal fusion, and even more choices in reporting the ICD-10-PCS codes.
The official definition from the Centers for Medicare & Medicaid Services (CMS) states that a Medicare overpayment is a payment that exceeds amounts properly payable under Medicare statutes and regulations. When Medicare identifies an overpayment, the amount becomes a debt you owe the Federal government.
The question asked in a physician query may be the most important element of the document. Query questions need to be as simple and concise as possible. The physician should have no doubt what the coder is asking.
Coding complications of transplanted organs has always been a coding dilemma. With the implementation of ICD-10-CM that didn’t change. However, coders have multiple directives to help in determining what a complication of the transplant is vs. non-transplant conditions and diseases.
With the implementation of ICD-10-CM came more codes for reporting many different conditions and diseases, and atrial fibrillation is one of those. For many years there was only one code available for reporting this condition, even when the physician further specified the type of atrial fibrillation that the patient had. In ICD-10-CM, there are four codes to report atrial fibrillation.
We have a case where the physician removes mucoid casts found during bronchoscopy. We have also seen mucus plugs removed during bronchoscopy. The MD performs bronchial washings then removes a large amount of tenacious and thick mucoid casts via bronchoscopy. Is this coded drainage, extirpation or excision? What body part is used?
The key to making the query process more efficient is to look for words or documentation while reviewing the record that may signal a potential query opportunity and to note the finding at that time. By the time a coder reaches the end of a record, documentation may have been found to eliminate the need for the query.
Question: This patient is noted to have “Lymphangitic carcinomatosis of lungs with mediastinal lymph nodes.” How would I code the diagnosis? Would I code metastatic cancer to the lung (C78.01) or metastatic cancer to the lymph nodes (C77.1)?
Coding these can be challenging for coders when trying to decipher the operative notes and terms that are used. The physicians are still using the terms excision and resection interchangeably and review of the entire operative note is required to select the appropriate root operation. Remember, it is the coder’s responsibility to determine the root operation based on the details from the physician in the operative report.
This would be considered a “mechanical” complication of the stent graft since the MD states it is a fracture of the endograft and it is folded over on itself. I would change T82.898A TO T82.598A for Other mechanical complication of other cardiac and vascular devices and implants, initial encounter. I did not use “displacement” because the surgeon did not state that the graft was displaced, only that it collapsed upon itself causing obstruction.