ICD-10 Challenges in the Cath Lab

Anne M. Pavlik, RHIT, is a Senior Education Consultant for Amphion Medical Solutions and can be reached at anne.pavlik@amphionmedical.com. 

ICD-10-PCS (International Clas-sification of Diseases, 10th revision, procedure coding system) was created to improve the coding of procedures to include more specificity, as well as to allow enough space for expansion in order to include technological advances in methods of treatment. While the increased detail in coding procedures provides a more accurate portrayal of a patient encounter, it does produce some challenges, particularly for the catheterization lab. Coders must familiarize themselves with the differences in the two systems and prepare to incorporate the changes into their daily workflow. Likewise, physicians and medical staff have a responsibility to learn and understand the magnitude of the shift to ICD-10-PCS in order to better support coders during the transition. Ensuring a successful changeover requires one key focus — practice. 

Root operation/intent of the 

procedure

Effective preparation for cath lab coding begins with recognizing the major challenges inherent within ICD-10-PCS. One of the most significant is defining procedural intent — was the focus of the cath lab procedure diagnostic or therapeutic? 

Diagnostic procedures are coded outside of the medical and surgical section. Therapeutic procedures, however, are captured within the medical and surgical section, and require coders to apply a root operation value that defines the intent of the procedure. 

The most common medical and surgical root operations for cath lab coding include:

• Dilation: Expanding an orifice or the lumen of a tubular body part; 
• Destruction: Physical eradication of all or a portion of a body part by the direct use of energy, force or a destructive agent; 
• Insertion: Putting in a non-biological device that monitors, assists, performs or prevents a physiological function, but does not physically take the place of a body part;
• Extirpation: Taking or cutting out solid matter from a body part; 
• Supplement: Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part; 
• Replacement: Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part. 

Coders are also responsible for applying the proper PCS definitions based on medical documentation. Improperly coding procedural intent, for example, coding for a replacement instead of a supplement, can result in a facility receiving the incorrect reimbursement; in this case, an overpayment. If the mistake is overlooked on the initial review, the claimed charges may be flagged when compared with a properly reported claim, thereby placing the organization at risk for penalties during an audit.  

The challenge of defining intent for some procedures lies in the differences between the operative description and the body of the operative report. Coders must remember to review the body of an operative report and not take the operative title at face value. A routine diagnostic procedure, such as a cardiac catheterization, may uncover the presence of a condition like atherosclerosis, which requires a physician’s immediate attention. Though the procedure title may identify a diagnostic intent, details in the body of the report may necessitate a coder applying one of the therapeutic root operations such as dilation or destruction.

Body part

The increased specificity in coding body parts adds another challenge to the ICD-10-PCS transition. Cath lab coding in ICD-9-CM (clinical modification) captures the body part in the procedure code as the name/number of vessels being treated. In ICD-10-PCS, the body part for specific vessels is captured by the “number of sites.” The ICD-10-PCS guidelines direct that 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. Consider, for example, a procedure on the left anterior descending coronary artery (LAD). Coders using ICD-9-CM need only document the vessel itself, while ICD-10-PCS requires the capture of each site that received treatment, even if it is in the same vessel. 

Approach

Following the body part, ICD-10-PCS captures the approach — the technique used to reach the procedure. Coders can make the common mistake of capturing a cath lab approach as percutaneous endoscopic. Visualization performed through the use of fluoroscopy needs to be translated as a percutaneous approach since it does not involve the use of an endoscope. Coders will capture a percutaneous approach value for the majority of cath lab procedures.

Device

Coders must next determine if they need to assign a device value for the procedure. ICD-10-PCS classifies devices as items that remain in a patient after a procedure is complete. Common cath lab devices associated with the root operation insertion include stents, pacemakers and defibrillators. 

When a percutaneous transluminal coronary angioplasty (PTCA) is performed, the assignment of the device value is based on the type of device inserted, if any. Treatment of two sites of a particular body part with two different devices requires two separate codes, whereas treatment of both sites with the same device requires only one. For example, if a physician treats the proximal and distal left anterior descending artery (LAD) with drug-eluting stents, then the coder will only assign one PCS-device code. However, a physician may opt to treat only one site with a drug-eluting stent and the other with just a balloon. In this case, the coder must assign a procedure code that includes a device value in order to document the stent and also assign an additional procedure code without a device for the use of the balloon without a stent placement.  

Coding devices for the replacement root operation requires coders to specify the type of material inserted. In a transcatheter aortic valve replacement (TAVR), coders have several options for device values, including autologous tissue, zooplastic tissue, and synthetic substitutes. To sort through coding complexities, coders have at their disposal an ICD-10 device key. The key takes a device term and equates it to a specific PCS description. For instance, when a physician uses a Hancock bioprosthetic valve for a TAVR, the device key will equate it to the PCS value for zooplastic tissue. 

Training techniques for an easy transition

Though the go-live date is right around the corner, coders still have time to prepare. 

While the new system shares some similarities with old, relying on General Equivalence Mappings (GEMS) between ICD-9 and ICD-10 is not sufficient. In fact, practicing ICD-10-PCS is most effective when coders ignore their knowledge of ICD-9 altogether. 

Another effective training technique is to incorporate practical application into a standard workflow. Such is the case with dual coding practices, which require coders to first code a report in ICD-9 and then code the same report immediately in ICD-10. Though it adds to the workload, dual coding forces coders to work within the new system on a day-to-day basis. 

Ultimately, a truly successful transition depends upon the quality of education support healthcare organizations provide to their coders, including access to training lessons and review tools to track progress. Implementing industry-proven training methods increases coders’ skill set and accuracy, thereby reducing the possibility of oversights come October 1.

Rising to the occasion

Without a doubt, the ICD-10-PCS transition will create a myriad of challenges for coding within the cath lab and throughout the healthcare industry. The preparation steps mentioned above: 1) learn the coding changes from ICD-9-CM and 2) train in practical application, are made more effective when using a third step — repeat. Expert proficiency in medical coding is earned over the course of years. Physicians and medical staff should acquire a general familiarity with these changes, and understand that the documentation contained within a procedure report directly affects coding and reimbursement. Only through the use of persistent and continuous preparation and collaboration can coders and healthcare organizations ensure successful go-live implementation. 

Acknowledgements. 

Thank you to Alisa Engel, RHIT, CPC-H for her contributions to the article.