Course C6. ICD-10-PCS Transplantation. SCHIMA ICD-10 C6 Attendee Handouts. Root Operation That Put In / Put Back or Move Some / All of a Body Part

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1 Course C6 January/February/March 2013 Root Operation That Put In / Put Back or Move Some / All of a Body Part Transplantation Definition Putting in /or on, all /or a portion, of a living body part taken from another individual or animal to physically take the place and / or function of all /or a portion of a similar body part. Transplantation A small number of procedures are represented by the root operation Transplantation and includes only the body part currently being transplanted. Examples of Transplantation procedures: Heart Transplant Kidney Transplant Lung Transplant Transplantation During the Transplantation, the native body part may or may not be taken out. The transplanted body part may take over all or a portion of it s function. Transplantation Qualifier values specify the genetic compatibility of the body part transplanted. Type of Transplant Qualifier Definition Character Allogenic 0 Taken from different individuals of the same species Syngeneic 1 Having to do with individuals or tissues that have identical genes, such as identical twins Zooplastic 2 Tissue from an animal to a human 1

2 Transplantation Coding Hint: PCS does not include corneas & heart valves in the Transplantation Root Operation. They are classified to Replacement as they are considered biologic or synthetic and not a complex body part. Transplantation Coding Hint, cont d. Transplantation vs. Administration (Body parts) vs. (cells) Don t confuse the two putting in autologous or nonautologous cells (i.e. bone marrow, pancreatic islet cells, stem cells) are coded to Administration. Transplantation Coding Transplantation Coding Liver transplant with donor matched liver. Bilateral lung transplant, using an organ donor match. Transplantation Coding Transplantation Coding Heart transplant using a porcine heart. Right kidney transplant using a twin brother s kidney. 2

3 Reattachment Root Operation That Put In / Put Back or Move Some / All of a Body Part Definition Putting back in or on all or a portion of a separated body part to it s normal location or other suitable location. Reattachment Separated refers to a body part that has been cut off or avulsed (the ripping or tearing away of a part either accidentally or surgically). Replacement Examples of Reattachment procedures: Reattachment of a severed finger Reattachment of an avulsed kidney Closed replantation of avulsed teeth of upper jaw Replantation of avulsed scalp Reattachment Reattachment Coding Coding Hint: Vascular circulation and nervous pathways may or may not be reestablished. Reattachment of severed left ear 3

4 Reattachment Coding Reattachment Coding Reattachment of right hand Endoscopic reattachment of an avulsed tendon of the left knee Reattachment Coding Reattachment of right severed fallopian tube MEDICAL & SURGICAL ROOT OPERATIONS Transfer: Moving, without taking out, all or a portion of a body part to another the location, to take over the function of all or a portion of a body part. Examples: Tendon transfer, skin pedicle flap transfer, skin transfer flap Additional Examples: Trigeminal to fascial nerve transfer Left scalp advancement flap to left temple Transfer right index finger to right thumb position 4

5 Transfer is used to represent procedures where a body part is moved to another location without disrupting its vascular and nervous supply. In the body systems that classify the subcutaneous tissue, fascia and muscle body parts, a qualifier is used to specify when more that one tissue layer was used in the transfer procedure, such as a musculocutaneous flap transfer. Body System Value: The body system value describes the deepest tissue layer in the flap. The qualifier can be used to describe the other tissue layers, if any, being transferred. Note: Free grafts are coded to the root operation of Replacement Case # 1: Patient underwent a left foot open flexor digitorum brevis tendon transfer. Case # 2: Patient underwent an endoscopic radial to median nerve transfer Case #3: Skin transfer flap closure of complex open wound, right chest MEDICAL & SURGICAL ROOT OPERATIONS: REPOSITION 5

6 Reposition: To reposition is to move all or a portion of a body part to its normal location or other suitable location. The Reposition root operation is used for those procedures where a body part is moved or relocated to a new position or location. The range of reposition includes moving the body part to its normal location or a new location to enhance the body part s ability to function. Examples of Reposition procedures include: reduction of fractures reposition of undescended testicle transposition of a nerve repositioning of a ligament. Reduction of a displaced fracture is coded to the root operation Reposition and the application of the cast or splint is not coded separately. Case # 1: Patient underwent an open reduction of a displaced fracture of the right humeral head. Case # 2: Patient underwent a bilateral percutaneous repositioning of his testicles 6

7 Case #3: Patient underwent a closed reduction with percutaneous internal fixation of a left intertrochanteric femoral fracture MEDICAL & SURGICAL ROOT OPERATIONS: RESTRICTION Restriction Root operations that alter the diameter/route of a Tubular Body Part There are four operations that belong to this group - Restriction - - Dilation -Bypass Restriction Definition: Partially closing an orifice or the lumen of a tubular body part Explanation: The orifice can be a natural orifice or an artificially created orifice Restriction Some of these conditions are: Esophagogastric fundoplication Cervical cerclage Restriction The root operation Restriction is coded when the objective of the procedure is to narrow the diameter body part or orifice. Restriction includes either intraluminal or extraluminal methods for narrowing the diameter. 7

8 ICD -10- PCS Restriction Additional examples of restriction Thoracotomy with banding of the left pulomary artery with extraluminal device Restriction of thoracic duct with intraluminal stent ICD -10- PCS Restriction Continued Non-incisional, trans-nasal placement of restrictive stent in lacrimal duct ICD -10- PCS Restriction * Since intraluminal or extraluminal clips are frequently used to accomplish the objectives of Restriction and procedures, careful review of the operative report is required. Research on the procedure technique may also be helpful. Restriction Coding Transvaginal cervical cerclage using Mcdonald technique Restriction Coding Restriction of thoracic duct with intraluminal stent Restriction Coding Clipping of anterior cerebral artery aneurysm via craniotomy 8

9 MEDICAL & SURGICAL ROOT OPERATIONS: OCCLUSION Definition: Complete closing an orifice or the lumen of a tubular body part Explanation: The orifice can be a natural orifice or an artificially created orifice. Examples: Fallopian tube ligation Ligation of inferior vena cava Uterine artery embolization (complete closing the vessel) Complete embolization of internal carotid-cavernous fistula Coding Guideline B3.12. vs. Restriction for Vessel Embolization If the objective of an embolization procedure is to completely close a vessel, the root operation is coded. If the objective of an embolization procedure is to narrow the lumen of the vessel, the root operation Restriction is coded. Example: 1. Tumor embolization is coded to the root operation, because the objective of the procedure is to cut off the blood supply to the vessel. Example: 2. Embolization of a cerebral aneurysm is coded to the root operation Restriction, because the objective of the procedure is not to close off the vessel entirely, but to narrow the lumen of the vessel at the site of the aneurysm where it is abnormally wide. 9

10 *Research on embolizations may be required to gain additional information about how the procedure is performed. The purpose of an embolization is to prevent blood flow to and area of the body. It is used during hemorrhage (i.e. arteriovenous AV malformation, cerebral aneurysms, GI bleeding, epistaxis, post-partum hemorrhage). However, the procedure has other uses, such as in the treatment of tumors and disorders of the portal vein. An artificial embolus is introduced (coils, particles, foam, plugs). Some of the common agents used to do this are sclerosing agents, ethanol, or Gelfoam. In order to code occlusions and restrictions correctly the coder must know if it is complete or partial, and physician documentation or additional query is essential. Coding Laparoscopy with bilateral occlusion of fallopian tubes using extraluminal clips Coding Coding Percutaneous ligation of left external jugular vein Open suture ligation of failed AV graft, right brachial artery 10

11 Coding Uterine artery embolization, right (completely closing the vessel) ROOT OPERATIONS: DILATION (7) & BYPASS (1) *No device used Definition Expanding an orifice or the lumen of a tubular body part. Explanation The orifice can be a natural orifice or an artificially created orifice. Accomplished by stretching a tubular body part using intraluminal pressure or by cutting part of the orifice or wall of the tubular body. Examples - PTCA, dilation of laryngeal stenosis, dilation of common bile duct The root operation dilation is coded when the objective of the procedure is to enlarge the diameter of a tubular body part or orifice. Includes both intraluminal and extraluminal methods of enlarging the diameter. A device placed to maintain the new diameter is an integral part of the dilation procedure and is coded to a sixth character device value in the dilation procedure code. Applicable Coding Guidelines: B4.4 Coronary Arteries The coronary arteries are classified as a single body part that is further specified by the 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. Applicable Coding Guidelines: B4.4 Coronary Arteries continued Examples: 1. Angioplasty of two distinct sites in the LAD coronary artery with placement of 2 stents is coded as Dilation of Coronary Arteries, Two Sites with Intraluminal Device 2. Angioplasty of two distinct sites in the LAD coronary artery one with stent placement and one without is codes separately as: Dilation of Coronary Artery, One Site with Intraluminal Device and Dilation of Coronary Artery One Site with No Device. 11

12 1. ERCP with balloon dilation of common bile duct 2. PTA of right radial artery stenosis 3. Laryngoscopy with intraluminal dilation of laryngeal stenosis 4. PTCA of 2 coronary arteries RCA with stent and LAD without stent 5. Hysteroscopy with balloon dilation of fallopian tubes Definition Altering the route of passage of the contents of a tubular body part. Explanation Rerouting content of a body part to a downstream area of the normal route, to a similar route and body part, or to an abnormal route or dissimilar body part. Includes on or more anastomoses with or without the sue of a device. Examples CABG, Colostomy formation Applicable Coding Guidelines: B3.6a Bypass Procedures Bypass procedures are coded by identifying the body part bypassed from and the body part bypassed to. The fourth character body part specifies the body part bypassed from and the qualifier specifies the body part bypassed to. Applicable Coding Guidelines: B3.6b Coronary Bypass Procedures Coronary arteries are classified by number of distinct sites treated, rather than number of coronary arteries or anatomic name of a coronary artery. Coronary artery bypass procedures are coded differently than other bypass procedures as described in guidelines B3.6a. 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. Applicable Coding Guidelines: B3.6c Coronary Bypass Procedures If an autograft is obtained from a different body part in order to complete the objective of the procedure, a separate procedure is coded. Example Coronary bypass with saphenous vein graft, excision of saphenous vein is coded separately. Coronary Artery Bypass Devices Type of Tissue Device Character Definition Autologous artery or vein 9 or A Tissue or organ is transferred into a new position in the body of the same individual Synthetic Substitute J Any type of synthetic substitute Nonautologous Tissue Substitute K Nonautologous allogenic donor; tissue implanted from one human to another 12

13 Coronary Artery Bypass Devices When assigning the device value, the key to remember is that to be considered a device, this needs to be material used as a graft (separated) and not moved over. When the internal mammary is loosened from one side and brought around to the occluded coronary artery, the artery is not used as free graft material in this case No Device is the appropriate qualifier. 1. Open colostomy, descending colon to abdominal wall 2. CABG of three coronary arteries using left autologous greater saphenous vein, harvested endoscopically 3. Right femoral-posterior tibial artery bypass using cadaver vein graft, open approach 4. Open gastric bypass with Roux-en-Y limb to jejunum 5. CABG of LAD using left internal mammary artery. Case # 1 CASE STUDIES Preoperative Diagnosis: Gastroesophageal reflux disease with biliary colic and cholecystitis Postoperative Diagnosis: Gasgtroesophageal reflux disease with biliary colic and cholecystitis Procedure: Laparoscopic Nissen fundoplication with laparoscpic cholecystectomy Case # 1 Description: Her abdomen was prepped and draped. A 5 mm stab incision was made to the left of the umbilicus. The abdomen was briefly explored with the laparascope, and we placed four 5 mm trocars across the upper abdomen. We exposed the gastroesophageal junction. We began by taking down the gastrohepatic window and cleaning up the right crus of the diaphragm. We then turned and took down the top most splenic short gastric vessels freeing up the fundus of the stomach We cleaned up the left crus of the diaphragm and created a nice window behind the esophagus. We wrapped the fundus of the stomach around the esophagus to create a nice loose, floppy Nissen fundoplication. Case # 1 And then we focused on the gallbladder. The dome of the gallbladder was elevated. We carefully skeletonized the cystic duct and cystic artery and then divided these between the Hemoclips. The remainder of the gallbladder was dissected free. The gallbladder was removed through the right lateral trocar site. The trocars were removed under laparoscopic visualization 13

14 Case # 2 Preoperative Diagnosis: ESRD secondary to dysplasia, peritoneal dialysis dependent Postoperative Diagnosis:ESRD secondary to dysplasia, peritoneal dialysis dependent Procedure: Living related donor renal transplant The midline incision and access to the transplant was completed in standard fashion. The donor kidney was procured in a separate procedure. The patient was systematically heparinized with 1,000 units intravenously. After 3 minutes cross clamps were placed and he donor kidney was transplanted and all vascular anastomoses were completed without complication and patient was transported to ICU Case # 3 Pre-op Diagnoses: Coronary atherosclerosis with unstable angina Hypertensive heart disease with CHF Type I Diabetes Post-op Diagnoses: Same Procedure: PTCA of LAD and RCA HPI: 62 year old female transferred from another facility after diagnostic cath showing two vessel CAD. This will be the patient s first cardiac intervention. Case # 3 Description of Procedure: The patient was sedated and brought to the cath lab. Via standard femoral artery access the patient underwent a angioplasty and DES stent placement in the LAD and a bare metal stent in the RCA. Good results were obtained. Case # 4 Pre-Op Diagnoses : Severe RLE atherosclerosis of native arteries with rest pain, Hypertension, ESRD, Alzheimer s dementia. Post-op Diagnoses: Same Procedure: Right femoral to posterior tibial with saphenous bypass Case # 4 Procedure Description: The right groin was opened and the femoral vessels were all dissected out and controlled individually, The medial calf was opened and an excellent greater saphenous vein was dissected out. We deepened the incision and identified the posterior tibial artery. After 2000units of heparin the posterior tibial artery was opened and an arteriotomy was made across the origin of the SFA. The saphenous vein was amputated and the graft was was anastomosed on both ends. Case # 5 Pre-op Diagnosis: Dysphagia Post-op Diagnosis: Esophageal stricture Operation: Gastroscopy with balloon dilation of esophagus Description: The Olympus was passed into the stomach and withdrawn back to the distal esophagus. A balloon dilation was performed in graduation from 36 French to 45 French and the balloon was inflated for 60 seconds. The stomach was normal on endoscopic exam. 14

15 Case # 6 Pre-op Diagnosis: Laceration with foreign body (broken glass) on the left little finger at the metacarpal phalangeal joint. Cut sustained when patient was washing dinner dishes in her house. Post-op Diagnosis: Same Procedure: Exploration of MP joint with excision and removal of foreign body broken glass. Description: An oblique incision was made over the MP joint. Incision was deepened and bleeders were fulgurated. By careful sharp and blunt dissection the foreign body was searched for. The foreign body was wedged underneath the foot of the tendon in the joint space; it was completely extracted and removed. The wound was irrigated and closed with 5-0 nylon. Case # 7 Pre-op Diagnosis: Acute anterior wall STEMI; Acute posterior wall STEMI two weeks ago. Post-op Diagnosis: Same Procedure: Off Pump CABG Description: The greater saphenous vein was harvested via incision from the left lower extremity, sufficient for 3 bypass grafts. The chest was opened through a median sternotomy incision. The pleural cavity was opened and the left internal mammary artery was mobilized. Using the vein graft the distal ic anastomoses were accomplished first. Individual segments of the saphenous vein were then sewn to the obtuse marginal, circumflex and distal right artery respectively with running sutures Case # 7 of 7-0 Prolene. The left internal mammary artery was then brought through a window in the pericardium and was sewn to the LAD with 8-0 Prolene. Three buttons of aortic tissue were excised and used as the 3 proximal anastomoses for saphenous grafts were completed with sutures 6-0 Prolene. The chest was closed in layers in usual fashion and dry sterile dressing applied. 15