By Maria N. Ward, MEd, RHIT, CCS-P
Many changes come with the first update of the new ICD-10 Procedure Coding System (ICD-10-PCS) for fiscal year (FY) 2017. The higher-than-usual volume of changes was to be expected since the update system has been in a holding pattern for several years due to implementation delays. And although this FY 2017 update came with 3,827 new codes, 491 code title revisions, and 12 deleted codes, the true impact on a well-trained coding professional should be minimal. For example, there was a change that affected all tables with a specific body part for the coronary arteries, but the change was simply for the terminology for that specific body part. The change was the result of public comments on the phrasing, and now instead of referring to the number of “sites” treated in the coronary arteries, the tables refer to the number of arteries treated.
Most of the changes made for the 2017 version of ICD-10-PCS were within the Heart and Great Vessels body system. The device value Zooplastic Tissue (8) was added to the bypass table for the Heart and Great Vessels (021). New qualifiers of Pulmonary vein right, left, and confluence were added, and an entire row was added for bypassing from the pulmonary trunk (P), pulmonary artery right (Q), and pulmonary artery left (R) to the innominate artery (A), subclavian (B), and carotid (D). The last change to this table was the change of Thoracic Aorta to Thoracic Aorta, Descending (W) and the addition of Thoracic Aorta, Ascending/Arch (X) in order to better specify if a bypass was done on the ascending or descending aorta. These changes to the separation of the ascending and descending aorta were also applied to all root operations that contained the Thoracic Aorta. This affected 11 additional tables.
Also affecting the Heart and Great Vessels body system is the addition of device values that indicate the number of coronary stents placed, as well as a device character for intracardiac pacemaker. Bifurcation was added as a qualifier to this body system, as well as to the Upper and Lower Arteries body systems. In the Repair table (02Q) and the Supplement table (02U), the aortic valve, mitral valve, and tricuspid valve are all placed into separate rows with new qualifiers for truncal valve, and the left and right atrioventricular valves.
The Lower Arteries body system now has the right and left common iliac arteries in separate rows. In the Upper Arteries body system, the azygos vein is separated onto its own row to allow for the Insertion (05H) of monitoring device (2) and neurostimulator lead (M). The right and left innominate veins have a separate row to allow for the Insertion (05H) of a neurostimulator lead (M). Of course, if a device can be inserted, then it can also be removed or repositioned, so the same three body parts were added to tables 05P and 05W.
Moving on to the Joints body system, the removal of lower joints (0SP) and revision of lower joints (0SW) tables now have three new rows, the first of which allows for the removal or revision of each surface in the hip and knee joints, which is eight new body part values. The other two new rows are for the addition of the qualifier Patellar Surface (C) of the right and left knee joints.
The last of the significant changes to the ICD-10-PCS tables are the new transplantation body parts of face (2), right hand (J), and left hand (K). Also of significance is the addition of the qualifiers allogeneic, related (2); allogeneic, unrelated (3); and allogeneic, unspecified (4). These qualifiers give additional specificity to the root operation of transfusion when administering bone marrow (W), stem cells, cord blood (X), and stem cells, hematopoietic (Y).
Only one new root operation was created, Perfusion, and it is only found in the Extracorporeal Therapies section. Of significance, however, is the change to the definition of the root operations Control and Creation. These changes are described in the next section of this article.
Root Operation Changes
The definition of the root operation Control has been expanded to include acute bleeding, as well as the previously defined postoperative bleeding. The definition of Control now reads “Stopping, or attempting to stop, postprocedural or other acute bleeding.” The use of a more definitive root operation will still take precedence over the use of Control if that more definitive root operation is used to stop the bleeding. As has always been the case, a more definitive root operation would include Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection. New examples provided for Control include control of bleeding duodenal ulcer and control of retroperitoneal hemorrhage.
The only other modification to a root operation definition is that of Creation. Creation has also been expanded beyond construction of new genital structures. The revised definition of Creation reads, “Putting in or on biological or synthetic material to form a new body part that to the extent possible replicates the anatomic structure or function of an absent body part.” Not only can Creation be used for gender reassignment, but now it can be utilized for the correction of congenital anomalies such as creation of a right and left atrioventricular valve from a common atrioventricular valve.
A new root operation, Perfusion (B), was added to Section 6 – Extracorporeal Therapies. Perfusion is defined as extracorporeal treatment by diffusion of therapeutic fluid. This new root operation was added in order to capture the significant amount of time, effort, and equipment utilized to perfuse and assess a donor organ. Organ perfusion is not captured in the organ procurement process, so a means of reporting this procedure was necessary in order to track patient outcomes and hospital utilization; both of which are important data.
Body Part Key Changes
There was only one body part correlation that was completely eliminated from the body part key, and that was the deletion of Ossicular Chain from the body part Auditory Ossicle, Left and Auditory Ossicle, Right. All other changes were additions or reassignment. The Ophthalmic Artery was moved from the Internal Carotid Artery, Left and Right, to Intracranial Artery. Also added to Intracranial Artery is the new specification of Internal Carotid Artery, Intracranial Portion. The body part Main Bronchus, Right now includes the terms Bronchus Intermedius and Intermediate Bronchus.
The Levator Ani Muscle was reassigned from the Perineum Muscle to the Trunk Muscle, Left and Right. Any procedures performed on the base of the tongue will now be assigned the body part of Pharynx. Filum Terminale has been added to the body part of Spinal Meninges. Finally, the body part Thoracic Aorta was revised to be Thoracic Aorta, Ascending/Arch, and it includes the Aortic Arch and the Ascending Aorta. The Aortic Intercostal Artery, Bronchial Artery, Esophageal Artery, and Subcostal Artery were all moved to the body part Upper Artery.
Device Key Changes
Multiple new device names were added to the list of intraluminal devices. These include endoprostheses and endovascular grafts. Cook Biodesign® Fistula Plug, Hernia Graft, and Layered Graft were added to Nonautologous Tissue Substitute, as was Cook Zenapro™ Layered Graft. Ceramic-on-ceramic bearing surface was added to Synthetic Substitute, Ceramic for Replacement in Lower Joints, and metal-on-metal bearing surface was added to Synthetic Substitute, Metal for Replacement in Lower Joints.
New Technology Additions for FY 2017
The seventh character qualifier to identify new technology added for FY 2017 is New Technology Group 2 (2). There are two additional approach values for FY 2017—via natural or artificial opening (7) and via natural or artificial opening endoscopic (8)—but neither is represented in the actual tables in Section X. The New Technology Device/Substance/Technology values are included in the table below.
|New Technology Device/Substance/Technology Values
||Andexanet Alfa, Factor Xa Inhibitor Reversal Agent
||Factor Xa Inhibitor Reversal Agent, Andexanet Alfa
||Defibrotide Sodium Anticoagulant
||Interbody Fusion Device, Nanotextured Surface in New Technology
||nanoLOCK™ interbody fusion device
||Magnetically Controlled Growth Rod(s) in New Technology
||MAGEC® Spinal Bracing and Distraction System
Spinal growth rods, magnetically controlled
||Skin Substitute, Porcine Liver Derived in New Technology
||MIRODERM™ Biologic Wound Matrix
|Zooplastic Tissue, Rapid Deployment Technique in New Technology
||EDWARDS INTUITY Elite valve system
INTUITY Elite valve system, EDWARDS
Perceval sutureless valve
Sutureless valve, Perceval
Guideline Changes for FY 2017
All changes to the 2017 ICD-10-PCS Coding Guidelines occurred in the Medical and Surgical Section Guidelines (Section 0). The first change was a simple change in B2.1a under the Body System General Guidelines. This guideline now states that general anatomical regions body systems can be used, instead of “should only” be used when the procedure is performed on an anatomical region. Examples added include chest tube drainage of the pleural cavity and suture repair of the abdominal wall.
Several changes were made in B3 – Root Operation Guidelines. The guidelines for multiple procedures added some additional examples, including:
- B3.2a – Excision of lesion in ascending colon and excision of lesion in transverse colon are coded separately
- B3.2b – Extraction of multiple toenails are coded separately
Clarification of an example of guideline B3.4a under biopsy procedures added the words “fluid in the” to the following passage: “Fine needle aspiration biopsy of fluid in the lung is coded to the root operation Drainage with the qualifier Diagnostic.”
To coincide with the terminology change related to coronary arteries, guidelines B3.6b and B3.6c—related to bypass procedures—changed “coronary artery sites” to “coronary arteries.” This terminology change is also reflected in B4.4, which incorporates the change of “coronary artery sites” to “coronary arteries.” It indicates that one procedure code is used when the same procedure is performed on multiple arteries utilizing the same device and qualifier values.
If angioplasty is done of the left obtuse artery and the left anterior descending artery and both arteries are treated with stents, one code is assigned for Dilation of Coronary Artery, Two Arteries with Two Intraluminal Devices. If the same arteries are treated, one with a stent and one without, two codes would be assigned; Dilation of Coronary Artery, one Artery with Intraluminal Device, and Dilation of Coronary Artery, One Artery with no device.
Guideline B3.7 also reflects a terminology change as it relates to the root operation Control, adding the phrase “or other acute” to the type of bleeding that can be classified as a Control procedure.
Guideline B3.9 clarifies that an autograft obtained from a “different procedure site” rather than different body part is coded separately. This means that a separate incision must be made in order to code the harvesting of graft material from the patient.
A significant change was made to guideline B4.2, clarifying that a body part is “typically” coded to the closest proximal branch of a body part if it does not have its own body part by adding information related specifically to the cardiovascular body systems. This guideline now includes the phrasing: “In the cardiovascular body systems, if a general body part is available in the correct root operation table, and coding to a proximal branch would require assigning a code in a different body system, the procedure is coded using the general body part value.” The example provided states that an occlusion of the bronchial artery is coded to the body part value Upper Artery in the Upper Arteries body system rather than to the body part value of Thoracic Aorta, Descending in the Heart and Great Vessels body system.
More Changes Online
This article does not represent an exhaustive list of the changes. The complete listing of all ICD-10-PCS updates for FY 2017 can be found at www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-PCS-and-GEMs.html. Because they were created for implementation purposes, the Reimbursement Mappings, the ICD-10-PCS Reference Manual, and the Development of the ICD-10 Procedure Coding System documents will no longer be updated.
Maria N. Ward (firstname.lastname@example.org) is a director of HIM practice excellence at AHIMA.
"FY 2017 Updates to ICD-10-PCS"
Journal of AHIMA