By Tina Bruce, MSHIM, MSHI, RHIA, CCS, CDIP
Coding professionals, clinical documentation integrity (CDI) specialists, auditors, and healthcare practices anxiously await the yearly release of ICD-10-PCS coding updates by the Centers for Medicare and Medicaid Services (CMS).
Health information management (HIM) professionals understand the importance of staying abreast of revisions made to the ICD-10-PCS Official Guidelines for Coding and Reporting.
This article will cover a few of the new and revised ICD-10-PCS codes and guidelines for FY 2021.
Two new guidelines were added to the ICD-10-PCS Coding Guidelines for FY2021.
The first was B3.18: Excision/Resection followed by replacement. This coding guideline is further clarified and used when an excision or resection of a body part is followed by a replacement procedure. Code both procedures to identify each distinct objective, except when the excision or resection is considered integral and preparatory for the replacement procedure.
This guideline would apply when a mastectomy is performed, followed by a reconstruction. Both the resection and the replacement of the breast are coded to fully capture the distinct objectives of the procedures performed.
Another example of the coding guideline’s application is esophagectomy, followed by reconstruction with colonic interposition. Both the resection and the transfer of the large intestine to function as the esophagus are coded to fully capture the distinct procedure objectives performed during this procedure.
Guideline B5.2b was also added to the FY 2021 guidelines of the Medical and Surgical section.
The guideline was added for the percutaneous endoscopic approach with extension of incision. This guideline is described in more detail as procedures performed using the percutaneous endoscopic approach made with incision or requiring an extension of the incision to assist in the removal of all or a portion of a body part or to anastomose a tubular body part to complete the procedure.
These procedures should be coded to the approach value percutaneous endoscopic. For example, this new approach coding guideline would apply when a laparoscopic nephrectomy with midline incision to remove the kidney.
Another example where this coding guideline can be applied is a robotic laparoscopic prostatectomy requiring an extension of the incision to remove the patient’s prostate. This should be coded to the Percutaneous Endoscopic approach value.
Additional revisions made to the ICD-10-PCS Coding Guidelines for FY2021 include B3.1b and B3.10c.
B3.1b revisions include the deletion of the procedure exceptions where this coding guideline would be applied. In FY 2021, the coding exception, mastectomy followed by breast reconstruction, where both resection and replacement of the breast are coded separately, has been deleted. This procedure coding guideline also will no longer be applied for mastectomies followed by breast reconstruction procedures.
Thus, the first bullet point under B3.10c has been modified to read, “If an interbody fusion device is used to render the joint immobile (containing bone graft or bone graft substitute), the procedure is coded with the device value Interbody Fusion Device.” This coding guideline revision removed the verbiage (alone or) from the bracket notations.
Supplementary root inclusions and examples no longer include free nerve grafts as a procedural example. Another change that you will see in the Medical and Surgical section for abdominal sympathetic nerves body part character is a definition which includes the renal nerve body part.
The devices within the Medical and Surgical section include several additions and removals.
For example, the DynaNail Mini for the Internal Fixation Device, Sustained Compression for Fusion in the Lower Joints device has been added to the Medical and Surgical section. A few significant deletions include the Cook Zenith Endovascular Graft Device from the Restriction in the Intraluminal Device, Branched or Fenestrated, Three or More Arteries for Restriction in Lower Arteries.
Finally, the Medical and Surgical section device for ICD-10-PCS value Synthetic Substitute reflects additions to the device definition for Barricaid Annular Close Device (aka ACD), IASD (Intraarterial Shunt Device, Covia), and V-Wave Intra-atrial Shunt System.
Next, ICD-10-PCS tables were added to capture fragmentation procedures performed in the upper and lower arteries using an ultrasonic core catheter or no device. These catheters allow physicians the ability to target the entire thrombus creating a thrombolysis effect, thus, helping the thrombolytic agent work faster and more effectively in breaking up the clot. These new codes will allow the capturing of embolectomies or thrombectomy procedures when performed in these body parts when performed with or without this specialized catheter or device.
The New Technology section underwent further updates, creating new tables for transfusions of Brexucabtagene Autoleucel Immunotherapy, which is found in ICD-10-PCS XW2 table for FY2021.
In supplement to the root operation, transfusion has another table which captures the COVID-19 ICD-10-PCS codes effective August 1.
In FY2021, the XW1 ICD-10-PCS table includes a new transfusion table where the characters for Device/Substance/Technology can vary with different qualifier characters. The noteworthy takeaway for this ICD-10-PCS table is that the transfusion table has two (2) different qualifier characters.
The outcome of these two different qualifier characters can produce different codes because the qualifier and device character are different.
According to CMS, these two tables are not regarded as a mistake or a conflict. CMS indicated the reason they aren’t considered an error or conflict is because section X contains root operations from multiple sections in ICD-10-PCS. The letter or number used to represent the root operation may change from year to year, depending on what letters or numbers were used in a particular root operation group (e.g., qualifier value).
Currently, in FY2020, the number two in the third axis of classification is used for table XT2 Monitoring, and because of system constraints, the same root operation value cannot mean two different things within the same root operation grouping.
According to CMS, the emergence of the SARS-CoV-2 virus and COVID-19, the disease it causes, as well as the new treatments that have followed, it is critical to be able to track the use of these treatments and their effectiveness in real time.
CMS implemented new procedure codes to allow Medicare and other insurers to capture the use of the therapeutics remdesivir and convalescent plasma for treating in-hospital COVID-19 patients. These new codes, which went into effect August 1, enable CMS to conduct real-time surveillance and obtain real-world evidence on the treatments’ efficacy.
In addition to reporting, Medicare and other insurers can use the codes to trend the use of COVID-19 therapies and facilitate monitoring and data collection.
There are 12 new codes for COVID-19 therapies. As HIM professionals capture these procedure codes, they will want to remember that some of the Device/Substance/Technology characters are repeated in the New Technology tables, and thus have more than one meaning.
For example, Table XW0 the Device/Substance/Technology character of G means Plazomicin Anti-infective and Sarilumab on different rows; H means Synthetic Human Angiotensin II AND Tocilizumab again on different rows. The Qualifier varies so that the codes are not exactly the same but be sure to carefully assign the right procedure with the appropriate device/substance/technology. According to CMS, this is the proper way these procedures should be coded because they would quickly run out of space if they did not do this.
Ensuring Voices are Heard
Annually, the ICD-10 Coordination and Maintenance Committee reviews recommendations and comments when updating ICD-10 code sets.
ICD-10-PCS codes will continue to be modified in order to capture accurate procedures and the growing technology being utilized in healthcare organizations. All authorities involved in CDI, coding, and data analysis must remain up to date to ensure proper implementation and use of ICD-10-PCS codes.
Industry specialists, including coders, auditors, CDI specialists, and HIM professionals, should play an active role by conveying recommendations and attending biannual ICD-10-CM/PCS Coordination and Maintenance Committee meetings. Who knows what will be on the coding horizon for FY 2022? Be sure to review the complete FY 2021 ICD-10-PCS addenda and updated ICD-10-PCS Official Guidelines for Coding and Reporting to assign the correct codes as directed by the classification’s guidelines.
Centers for Medicare and Medicaid Services (CMS). 2021 ICD-10-PCS. August 11, 2020. www.cms.gov/medicare/icd-10/2021-icd-10-pcs.
CMS. ICD-10 Coordination and Maintenance Committee Meeting. March 17, 2020. www.cms.gov/files/document/march-2020-agenda-and-handouts.pdf.
CMS. “CMS announces new hospital procedure codes for therapeutics in response to the COVID-19 Public Health Emergency.” July 30, 2020. www.cms.gov/newsroom/press-releases/cms-announces-new-hospital-procedure-codes-therapeutics-response-covid-19-public-health-emergency.
Tina Bruce ([email protected]) is an assistant professor at San Juan College and an HIM consultant. She is an AHIMA-approved ICD-10-CM/PCS trainer, AHIMA-approved revenue cycle trainer, and AHIMA-approved CDI trainer.
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