Tips & Expertise: Breaking Down Vascular Interventional Radiology Coding for ICD-10-PCS Part 1 Webinar Q&A

Q:  What is the PCS approach for VIR procedures performed via cutdown?
A:  The fact that cutdown was used to access the vessel does not impact the approach value. Cutdown means that an incision was made in the skin and subcutaneous tissues so the artery could be accessed either through percutaneous or open (arteriotomy) means.  Arteriotomy is an incision in the artery for placement of instrumentation. Cutdown could be open or percutaneous approach, but if an arteriotomy is made, it is coded as an open approach.

Q:  If the planned procedure is angioplasty, but the procedure was aborted before dilation could occur, how is the case coded? And what about angioplasty with failed stent insertion?
A:  There are 3 different Coding Clinics that address these scenarios from Third Quarter 2019. The answer depends on the intent of the procedure and which procedures were actually completed.

• If diagnostic imaging was performed and angioplasty was attempted but failed, assign a code from the Fluoroscopy tables to report angiography.
• If the patient presented with the intent to perform angioplasty for a lesion already identified – in other words, no diagnostic imaging was performed – and guiding shots were used to place catheters, but the angioplasty was unsuccessful, assign root operation Inspection.
• If angioplasty was performed with the intent to place a stent, but the stent could not be deployed, assign root operation Dilation with the No Device 6th character of Z. Even though the stent could not be placed, angioplasty was still performed.

It is important to note that a procedure does not have to be successful to code. For example, of lower extremity angioplasty failed and the physician determined that the lesion would have to be treated in an OR, it is still acceptable to code the angioplasty as long as the lesion was crossed and dilation occurred, even if the results were less than favorable.

Q:  Should angiography be coded when a patient comes in for an intervention and has already had imaging done? Angiography was done to confirm the lesion and for guiding shots.
A:  Official advice from Coding Clinic is conflicting about the coding of angiography during the same encounter as an intervention. Haugen Academy applies coding guideline B3.1b in this scenario, which states “Procedural steps necessary to reach the operative site and close the operative site, including anastomosis of a tubular body part are also not coded separately.” Percutaneous interventions cannot be performed without fluoroscopic imaging. When performed as guiding shots, angiography is a procedure necessary to reach the operative site. Haugen Academy does not recommend coding angiography unless it was performed for diagnostic purposes. Indications for coding angiography would be if it was the only procedure performed, if the findings of angiography led to the decision to perform the intervention, or if a complication arises during the procedure that necessitated additional imaging.

Q:  What is the root operation for placement of a covered stent to treat arterial dissection? Is it still Dilation or does the root operation change since it’s not actually dilating the vessel?
A:  In ICD-10-PCS, procedures are coded according to the intent. When a covered stent is placed to treat an arterial dissection, the intent is to treat the existing dissection and prevent further arterial dissection rather than to dilate the vessel. This is coded to the root operation Insertion (Putting in a nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part) with the device value “D” for Intraluminal Device.

Q:  We’ve been told that we can’t code thrombectomy performed using an aspiration catheter. Is this true?
A:  ICD-10-PCS codes are assigned based on procedure intent. The definition of Extirpation does not differentiate between types of devices used to remove the blood clot. In CPT coding, coronary artery thrombectomy can only be coded when performed using mechanical means and the code specifically prohibits reporting aspiration thrombectomy in the coronary arteries. This guideline does not apply to ICD-10-PCS.