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Avoiding an MI When
Coding Cardiac
Catheterization and
Percutaneous Coronary
Intervention
Scot Nemchik, CCS VP of Coding Education and
Compliance, IOD Incorporated
Elsevier Clinical Solutions
May 14th, 2015
HURRICANE PCI
http://hurricanesolution.com/hurricanes-a-source-of-massive-destruction/
Objectives
Understand the sweeping changes to
PCI coding in ICD-10-PCS
Learn what areas of the medical record
to focus on to identify reliable source
data
Understand the benefit of P&P as an
intermediate solution documentation
shortcomings
Understand how device keys and
contrast guides can help coders
make quicker and more accurate
decisions
Understand the pitfalls to avoid when
coding PCIs in ICD-10-PCS
| 5
CUMULATIVE EFFECT
• PCIs alone are challenging, combine that with challenges associated with
commonly-associated procedures….
• Basic strategies can help us overcome productivity/accuracy challenges
Percutaneous
Coronary
Intervention
Optimized PCI Coding in ICD10-PCS
| 7
PCI: BODY PART
0 2 7 1 3 4 Z
Ex.: PTCA with DES, 2 sites, perQ
• The coronary arteries are classified as a
single body part that is further specified by
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.
• Examples: Angioplasty of two distinct sites in
the left anterior descending coronary artery
with placement of two stents is coded as
Dilation of Coronary Arteries, Two Sites, with
Intraluminal Device.
http://www.birminghamheart.com/index.php?Page=s9
| 8
PCI: BODY PART
• Ordinarily, specification of site is very good…
• In other words, this is very much a coding issue, much less a documentation issue
| 9
PCI: APPROACH
0 2 7 1 3 4 Z
Ex.: PTCA with DES, 2 sites, perQ
• A percutaneous approach (character value 3) involves entry,
by puncture or minor incision, of instrumentation through the
skin or mucous membrane and any other body layers
necessary to reach the site of the procedure. The access
location for this approach is the skin or mucous membrane
with instrumentation such as needles or catheters being used
to reach the operative site.
• Not much debate here, by definition, PCIs are percutaneous
| 10
PCI: DEVICES
 Optimized device value assignment for PCIs begins with the coder quickly
identifying if a stent is a DES or BMS
 Appendix D: Device Key and Aggregation Table is useful, but not completely
adequate
 A comprehensive stent-to-device value relationship key is a better idea, but
needs to be maintained
http://www.slideshare.net/quizzito/bioabsorbabledrugeluting-cardiac-stent-analysis
Function
DES
DES
DES
Name
TAXUS™ Liberté™
ION™
Promus PREMIER™
Manufacturer
Boston Scientific
Boston Scientific
Boston Scientific
DES
DES
DES
DES
DES
DES
DES
DES
DES
DES
DES
PROMUS Element™ Plus
Coroflex® ISAR
Cypher®
Nevo™
Endeavour
Resolute Integrity
Resolute Onyx™
Firehawk®
Xience V
Orsiro
Zilver
Boston Scientific
B Braun
Cordis
Cordis
Medtronic
Medtronic
Medtronic
MicroPort
Abbott Vascular
Biotronik
Cook Medical
Comment
Peripheral DES
10
PCI: DEVICES
0 2 7 1 3 4 Z
Ex.: PTCA one site, PerQ…Device TBD
| 12
PCI: QUALIFIERS
0 2 7 1 3 4 Z
Ex.: PTCA with DES, 2 sites, perQ
• Codes describing PTAs on bifurcations have been around for a
while, this concept goes back to ICD-9 and was designed to
capture data related to technically challenging bifurcated
lesions
• True bifurcations, where both segments of the bifurcation —
meaning the main vessel and the side branch vessel — are
involved are between 10 to 30 percent…
http://www.cathlabdigest.com/articles/Current-Treatment-Bifurcation-Lesions-and-a-Dedicated-Stent
| 13
PCI: QUALIFIERS
There are actually dedicated bifurcated stents (DBS), understanding the device names can help coders ID
procedures on bifurcated lesions involving stent insertion
….a comprehensive stent-to-qualifier value relationship key is a good idea, but needs to be maintained
Function
DBS
DBS
DBS
DBS
Name
SideKick™
Frontier™
Invatec Twin-Rail™
Nile CroCo™
Manufacturer
Y-Med
Guidant/Abbott
Invatec
Minvasys
DBS
DBS
DBS
DBS
DBS
DBS
DBS
SLK View™
Stentys™
Petal™
Antares™
Sideguard™
Tryton™
Axxess™
Advanced Stent Technology
Stentys
Boston Scientific
Tireme Medical Inc
Capella
Tryton Medical
Devax
Comment
DES
DES
DES
http://www.cathlabdigest.com/articles/Current-TreatmentBifurcation-Lesions-and-a-Dedicated-Stent
13
Along for the Ride:
Major Players
Procedures CommonlyPerformed with PCI
| 15
CONTRAST
• Back to cardiac catheterization and coronary angiography performed in
the same setting as PCI…
• ICD-10 requires coders to identify the type of contrast used for contrastbased procedures, current options include:




0, High Osmolar
1, Low Osmolar
Y, Other Contrast
Z, None
• Contrast related challenges can be overcome by:



Keeping in mind standard of care for contrast media utilization
Helping coders understand where contrast details may be found
Providing a dynamic key to help coders quickly relate contrast names to PCS character
values
| 16
CONTRAST…AND COMPARE
Compound
Name
Osmolality
Ionic
Diatrizoate (Hypaque, Cystograffin, Gastrograffin)
High
Ionic
Ionic
Iothalamate (Conray, Cysto-Conray)
Ioxithalamate (Telebrix)
High
High
Ionic
Metrizoate (Isopaque)
High
Non-ionic
Iobitrol (Xenetix)
Low
Non-ionic
Iohexol (Omnipaque)
Low
Non-ionic
Iomeprol
Low
Non-ionic
Non-ionic
Non-ionic
Non-ionic
Iopamidol (Isovue)
Low
Iopentol (Imagopague, Ivepague)
Iopromide (Ultravist)
Ioversol (Optiray)
Low
Low
Low
Non-ionic
Ioxilan (Oxilan)
Low
Ionic
Ioxaglate (Hexabrix)
Low
Non-ionic
Iodixanol (Visipaque)
Iso-osmolar
Non-ionic
Iotrolan (Isovist)
Iso-osmolar
| 17
IMAGING MODALITY
• ICD-10 requires coders to identify the
imaging modality used during
angiography, ventriculography:
 0, Plain radiography
 1, Fluoroscopy
• Imaging-related challenges can be
overcome by:
 Keeping in mind standard of care for
intra-cath/PCI imaging
During angiography/angiocardiography, the physician visualizes the
coronary arteries and chambers, most commonly the LV, real time…this
is accomplished using FLUOROSCOPY!
Along for the Ride:
Minor Players
Procedures CommonlyPerformed with PCI
| 19
OTHER RELATED PROCEDURES
There are certain other procedures that may be performed in conjunction with PCI, some
more common than others, tips for mastery are included below:
3 E 0
3 3 P Z
Ex.: Integrillin infusion via peripheral vein
Glycoprotein iib/iiia inhibitors



Brand Name
Generic Name
Aggrastat®
Tirofiban
Integrillin®
Eptifibatide
ReoPro®
Abciximab
Understanding drug names (brand and generic) is critical!
Understanding where to find them is essential!
Understanding route of administration is key!
GP iib/iiia inhibitors are administered intravenously
Just by knowing the above, the coder can immediately reduce their options from five to
two…
| 20
OTHER RELATED PROCEDURES
3 E 0 3
3 1 7
Thrombolytic agents

Understanding drug names is critical! You coders
should –ase these!
Generic Name

Understanding where to find them is essential!

Understanding indications is useful!
Urokinase

Understanding route of administration is key!
Alteplase
Streptokinase
Reteplase
Qualifier value 7, Recombinant Human-activated
Protien C is actually Xigris, and has no applicability
in the PCI setting…
Tenecteplase
| 21
OTHER RELATED PROCEDURES
• Fractional Flow Reserve (FFR)



C
Consider creating a device key that relates device name
to device function:
Function
FFR
FFR
FFR
FFR
FFR

4 A 0 3 3
Name
PressureWire™ Certus™
PressureWire™ Aeris™
Verrata®
Primewire Prestige®
Sensis
Manufacturer
St. Jude Medical
St. Jude Medical
Volcano
Volcano
Volcano
Not much to worry about here, procedure is inherently
percutaneous, we know these are coronary in
nature…BUT
Create a P&P that directs your coders to one value or the
other…or both
Beware the encoder Kool-Aid…
Fractional flow
reserve technically
measures
both flow (5) and
pressure (B)….
| 22
OTHER RELATED PROCEDURES
• Intravascular ultrasound (IVUS)
B 2 4
Z Z 3
 Not much to worry about here, decisionmaking limited to single coronary artery (0) vs.
multiple coronary arteries (1)
 Consider creating a device key that relates
device name to device function:
Function
Name
Manufacturer
Comment
IVUS
IVUS
IVUS
IVUS
IVUS
Visions® PV
Revolution®
Eagle Eye®
OptiCross™
iCross™
Volcano
Volcano
Volcano
Boston Scientific
Boston Scientific
Peripheral IVUS
IVUS
Kodama® HD-IVUS
ACIST
http://www.sinaigrace.org/?id=94&sid=1
Intravascular spectroscopy (8E023DZ)is relatively uncommon,
but offers little coding resistance!!
23
BLUE SKIES AHEAD!
REINFORCE GUIDELINES
PROMOTE MECHANICAL UNDERSTANDING OF ICD-10-PCS
UNDERSTAND INDICATIONS FOR INTERVENTIONS
CREATE KEYS (DEVICE, CONTRAST, MEDS)
UTILIZE P&P TO FILL GAPS, COUNTERACT PCS’
TENDENCY TO PRESENT ALL OPTIONS
PREPARE TO SUCCEED!
http://www.huffingtonpost.com/mario-livio/out-of-the-clear-blue-sky_b_1661903.html
| 24
CITATIONS
BioPortal
Whetzel PL, Noy NF, Shah NH, Alexander PR, Nyulas C, Tudorache T, Musen MA. BioPortal: enhanced
functionality via new Web services from the National Center for Biomedical Ontology to access and use
ontologies in software applications. Nucleic Acids Res. 2011 Jul;39(Web Server issue):W541-5. Epub
2011 Jun 14.
Excellent resource for contrast osmolarity (Slide 14)
24
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