By Maria N. Ward, M.Ed., RHIA, CCS, CCS-P
There has been an increase in the number of possible codes in ICD-10-PCS every year since its implementation. With the Fiscal Year (FY) 2020 ICD-10-PCS code changes, effective October 1, 2019, the tides have turned. In the Medical and Surgical section, the annual update from the Centers for Medicare and Medicaid Services (CMS) has resulted in a net change of -1,382 codes. And despite the net increase of 80 codes in the Radiation Therapy section and hundreds of additions in other sections, altogether the FY 2020 changes to ICD-10-PCS resulted in 1,322 fewer codes.
In the Central Nervous System and Cranial Nerves body system of the Medical and Surgical section, CMS added the new qualifier value Subgaleal Space to the root operation Bypass for the Cerebral Ventricle body part. Because of the absorptive capabilities of the subgaleal space, placement of a ventriculosubgaleal shunt is common practice for drainage of excess cerebrospinal fluid, especially in pediatric patients with hydrocephalus. The addition of this new qualifier allows for the reporting of this detail.
In the Heart and Great Vessels body system, the qualifier value Innominate Artery has been added for the thoracic aorta body part value for the root operation Bypass. The deployment of a prosthetic heart valve can lead to coronary obstruction, so the options for the coronary artery body parts have been added to the Insertion table to capture placement of a stent(s). Additionally, a stent may be placed in a coronary artery to seal a perforation following an atherectomy. For this reason, the coronary artery body part options have been added to the Supplement table as well.
In table 031, Bypass of Upper Arteries, the qualifier value for Lower Extremity Vein has been added to five rows, allowing for the capture of bypass fistula procedures performed from the innominate, subclavian, axillary, and brachial arteries to a lower extremity vein such as the femoral vein. New rows were also added to capture bypass from the radial or ulnar artery to a lower arm vein via a percutaneous approach. These are now the only body parts that have the percutaneous approach option. The approach value “percutaneous” allows the capturing of arteriovenous fistula creation using a magnetic-guided radio-frequency technique such as the WavelinQ system. The new device value for Intraluminal Device, Flow Diverter has been added to table 03V, Restriction, Upper Arteries in the Upper Arteries body system.
Originally, the qualifier value Bifurcation was proposed to assist with data capture for procedures performed on the coronary arteries. However, when it was added to the PCS tables, it was also added to the upper and lower arteries body systems. Coding Clinic and other sources have indicated that this data is not as difficult to capture and therefore is not useful, justifying the removal of this qualifier from the upper and lower arteries that led to much confusion for coding professionals. Removal of this qualifier from Dilation and Extirpation in the Upper Arteries body system and Lower Arteries body system, as well as from Restriction in the Lower Arteries body system, eliminates 1,845 codes from ICD-10-PCS.
In table 06L, Occlusion of Lower Veins in the Gastrointestinal body system, the body part for Gastric Vein has been moved onto the row with Esophageal Vein to allow coding of transorifice or endoscopic procedures such as esophagogastroduodenoscopy with ligation of gastric varices, where occlusion of the gastric vein is performed. This change is consistent with previous changes made to the table for the body part value Esophageal Vein. In table 0D1, Gastrointestinal Bypass, a new row has been created for the general body part value Small Intestine, which will allow for coding of Bypass procedures when the specific segment of the small intestine cannot be determined. Because a patient’s normal gastrointestinal anatomy can change when they have procedures done, it may become difficult for a surgeon to identify the specific segment of the intestine, so having the general term Small Intestine will provide better data accuracy. The same concept applies with the addition of the new row for the general body part value of Large Intestine. One example of when this value might be used is when a colostomy is performed on a patient with a previous colon resection. In addition, a new row has been added to the Transfer table 0DX to capture the use of the large intestine as a means of creating a vagina.
One of the biggest FY 2020 changes for ICD-10-PCS is regarding procedures performed on the breast and the skin that covers the breast. Mammary tissue makes up the contents of the breast, and that tissue lies below the skin. For this reason, the approach value External has been removed from multiple rows in multiple tables in the Skin and Breast body system. In the Replacement table for Skin and Breast, External Approach, we see that the device value for Nonautologous Tissue Substitute has been placed on a separate row with the exact same body parts, so that the new qualifier value for Cell Suspension Technique could be added for Autologous Tissue Substitute. Cell suspension requires harvesting of a small split-thickness skin sample from the patient, which is then put through a process where the epidermis is separated from the dermis and a mix of several cell types are then suspended in a solution that can ultimately be sprayed or dropped on the prepared graft recipient site. This solution will eventually become a permanent layer of the patient’s own skin without the use of any fixators, such as sutures.
In the Subcutaneous Tissue and Fascia body system, the new device value Subcutaneous Defibrillator Lead has been added to the Subcutaneous Tissue and Fascia, Chest body part in the Insertion table. If we insert a device, we have to be able to Remove and Revise it as well, so in table 0JP, the device value for Subcutaneous Defibrillator Lead has been added for the body part value of Trunk rather than creating a new row for Chest. This aligns with the Cardiac Rhythm Related Device value in this table.
For the insertion of a device into the Upper Bones body part values for the humeral shaft, left and right have been separated onto a new row, adding the new device value Internal Fixation Device, Intramedullary Limb Lengthening. This new value distinguishes this device from the Intramedullary Fixation Device. This same addition was applied to a newly created row in the Lower Bones for body part values of right and left femoral shaft and tibia.
The final update in the Medical and Surgical section is in the table 0WC, Extirpation, Anatomical Regions General. A new row has been added that provides body part values for upper and lower jaw, allowing for evacuation of a hematoma or removal of a foreign body from the mandibular and/or maxillary spaces.
While this is a high-level review of some of the major changes in the Medical and Surgical section, complete review of all updates to the tables, resources, and guidelines is best practice for all coding professionals.
Maria N. Ward (firstname.lastname@example.org) is a director of HIM practice excellence at AHIMA.
"Fewer Codes for 2020 in ICD-10-PCS"
Journal of AHIMA