Q:  Can you explain when the approach for laparoscopically-assisted procedure through an orifice would be used?
A:  This approach was added to the GI system in fiscal year 2018 to report a laparoscopically-assisted anal-pull through procedure.  This procedure is performed on patients with Hirschprung’s disease. Hirschprung’s disease is a congenital disorder in which nerve ganglions in a segment of bowel are absent.  This causes inability to move the bowels.  In an anal pull-through procedure, the affected bowel is removed, and the healthy portion of bowel is pulled down to the anus.

Q:  How do you code creation of a J-pouch?
A:  Ileal pouches include the J-pouch and S-pouch.  These procedures allow bypass of the small intestine to the anus after the colon and rectum have been removed.  Since this is a more involved procedure than simply reconnecting the ends, it is coded to the root operation Bypass.

Q:  What qualifier do you use if a procedure is done for both diagnosis (i.e. biopsy) and also therapeutic?
A:  If one procedure is performed to remove a lesion for therapeutic treatment and that lesion is also sent to pathology, a single code is reported with the qualifier Z, No Qualifier.  If the sole intent of the procedure is to sample tissue to obtain a diagnosis, the qualifier X, Diagnostic, is used.  If there are two separate procedures, one to obtain a pathological diagnosis and another to remove a lesion in toto, two separate codes are reported: one with the qualifier X, Diagnostic, and one with the qualifier Z, No Qualifier.

Q:  Coding Clinic, Second Quarter ICD-10 2019 Pages: 15-16 states that we wouldn't code the scope to check for leaks since it isn't a separate diagnostic exam. Do you think we should use that guidance since it is more current than the previous Coding clinic that stated to code the scope?
A:  There is conflicting advice regarding coding for endoscopy to check for leaks following a procedure.  In Coding Clinic, Second Quarter 2019, the advice is to omit the Inspection code when an upper endoscopy is performed to check for leaks during a laparoscopic Roux-en-Y reversal procedure because a separate diagnostic exam was not performed.  In Coding Clinic, Second Quarter 2017, the advice is to code an Inspection procedure for sigmoidoscopy performed following low anterior resection to check for leaks based on coding guideline B3.11c, which states:

“When both an Inspection procedure and another procedure are performed on the same body part during the same episode, if the Inspection procedure is performed using a different approach than the other procedure, the Inspection procedure is coded separately.”

Since these articles present conflicting advice with different rationales, we have submitted this question to Coding Clinic for clarification.  In the meantime, we recommend organizations develop an internal policy regarding whether these endoscopic procedures should be reported.

**The coding information and guidance in this post is valid at the time of publishing. Readers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.

Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS Trainer

Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS Trainer

Senior Consultant

Kristi is a senior consultant with more than 25 years of industry experience; she is responsible for the development of web-based, instructor-led, and webinar training materials; conducting training in ICD-10-CM/PCS and CPT; and performing DRG and APC audits. Kristi has an extensive background in coding education and consulting and is a national speaker and published writer on topics related to ICD-10 and CPT coding and code-based reimbursement. She has designed and developed training programs for inpatient and outpatient hospital-based coding, with a focus on vascular interventional radiology, interventional cardiology, orthopedics, and obstetrics.

Kristi has served the Colorado Health Information Management Association (CHIMA) as board Director, co-chair of the Data Quality Committee, and co-chair for the ICD-10 Task Force. She is also a past president of the Northern Colorado Health Information Management Association (NCHIMA). Kristi is the proud recipient of the 2011 AHIMA Triumph Award for Mentoring for her voluntary work as the “Coder Coach.” She has also received awards from CHIMA for Distinguished Member (2018) and Outstanding Volunteer (2013) and from AHIMA for Roundtable Achievement in Coding Excellence (RACE).


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