Coding, Classification and Reimbursement

PCS - hemoclipping of AVM in the stomach

  • 1.  PCS - hemoclipping of AVM in the stomach

    Posted 12-02-2015 08:13

    Need some help.  The physician did an EGD due to GI bleed, there was a single arteriovenous malformation noted in the gastric body.  Two hemoclips were placed on the AVM.  The physician did not identify the artery or the vein involved.  How would you code this??

    I believe that the intent would be to occlude the AVM, so I started down that path and got 04LY_CZ - occlusion of lower artery w extra luminal device (need approach) and 06LY_CZ - occlusion of lower vein w extra luminal device (need approach).

    My problem with those codes are that the only options for approach are open, percutaneous, or percutaneous endoscopic.  No option for via natural or artificial opening endoscopic.

    The other code I was looking at, but I don't think it meets the intent and I can't code the device...was 0DQ68ZZ - Repair Stomach, Via natural or Artificial Opening Endoscopic.

    I did send this to coding clinic...but would appreciate the benefit of all of the brain power AHIMA represents.

    Thank you,

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    Kathy Completa
    Coding and Documentation Educator
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  • 2.  RE: PCS - hemoclipping of AVM in the stomach

    Posted 12-02-2015 08:49
    Edited by Jodi Kingley 12-02-2015 09:39

    Hi Kathy:

    I researched a bit about gastric AVMs and from what I found, they intervene in the arterial portion. You could query to determine definitively if they did the procedure on the artery or vein or both. 

    I looked in the index under clipping, aneurysm and it directs you to see Restriction using extraluminal device. There is an entry for restriction- gastric - 04V2.

    Then you can complete the code: 04V24CZ- Restriction of gastric artery, extraluminal device, percutaneous endoscopic approach.

    For the vein: 06V2...

    Hope this helps!

    Jodi

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    Jodi Kingley, CCS
    Inpatient Coder
    Princeton HealthCare System



  • 3.  RE: PCS - hemoclipping of AVM in the stomach

    Posted 12-10-2015 17:13

    Hi everyone.  I agree with Kathy.  I code restriction of an artery in the gastric area percutaneously,  endoscopically with  extraluminal device as 04V24CZ. They are restricting the lumen, not completely occluding it (from what I read). The notes in my codebook say, "Definition:  Partially closing an orifice or the lumen of a tubular body part and,. Explanation:  The orifice can be a natural or an artificially created orifice". This is according to the AMA ICD10 pcs book for 2016.

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    Cheryl Anderson
    Coder/Rev. Management/Auditor



  • 4.  RE: PCS - hemoclipping of AVM in the stomach

    Posted 12-10-2015 21:03

    Sorry Jodi, I meant to use your name.

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    Cheryl Anderson
    Coder/Rev. Management/Auditor



  • 5.  RE: PCS - hemoclipping of AVM in the stomach

    Posted 12-03-2015 08:37

    Wouldn't this be similar to the scenario in Coding Clinic 4Q 2014 p 20?  In this one a bleeding duodenal ulcer was treated with multiple clips applied to the vessels.  The advice was to code to root operation Repair.  Rationale was:  Most of the body’s organs and tissues are vascular, and they bleed when cut or eroded. Repair of a cut or eroded body part is coded to the body part repaired, rather than to a vascular system body part. 

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    Nancy Martilik
    Asst. Director of Education
    Health Information Associates



  • 6.  RE: PCS - hemoclipping of AVM in the stomach

    Posted 12-04-2015 08:15

    Nancy,

    We did end up coding it to Repair following that Coding Clinic, because it allowed us to name the body part and choose the correct approach.  I still think that the intent was occlusion - and with that code we could use extraluminal device, but not identify where it was located other than lower artery.

    The reason I was questioning the repair following the coding clinic you mentioned is that in the example it is for an ulcer where the tissue was "eroded" - I don't believe that is the case with the AVM.

    I did send this question to coding clinic for clarification.

    Thank you all for your input.  I will let you know what Coding Clinic says.

    Kathy

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    Kathy Completa
    Coding and Documentation Educator



  • 7.  RE: PCS - hemoclipping of AVM in the stomach

    Posted 02-19-2016 08:59

    I am having an issue with this procedure right now, did CC ever reply to you?  I am just really struggling with coding this as a repair during a colonsocopy and sending it to a major OR procedure DRG.

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    Angela Susott
    Coding Compliance Auditor



  • 8.  RE: PCS - hemoclipping of AVM in the stomach

    Posted 02-19-2016 09:45

    Angela,

    Unfortunately I have not received a response from Coding Clinic yet. 

    Kathy

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    Kathy Completa
    Coding and Documentation Educator



  • 9.  RE: PCS - hemoclipping of AVM in the stomach

    Posted 02-19-2016 12:50

    Thank you Kathy for your response.

    This is my scenario:  

    Postop DX: five ascending colon AVMs status post submucosal injection, argon plasma coagulation and hemoclip placement. Cecal polyp status post APC ablation.

    In the cecum, there was a 4mm AVM, I used the APC to destroy the AVM. There was a 4 mm polyp there that I destroyed using the Argon Plamsa Coagulator performing ablation. There were four more AVMs noted ranging in size from 4 mm to 1.5 cm. I injected the remainder of these with saline and then used the APC to destroy them. I then placed Hemoclips over the two larger AVMs. Patient tolerated the procedure well and no apparent complications.
     
    I believe destruction should be used for the APC...but then I feel like the Hemoclips were used just to control post APC bleeding and used the following CC although I-9 to come up with my reasoning.  If I use repair for the Hemoclips I will end up in a major or small/large bowel DRG for a colonsocopy...eek!  Thoughts?
     
    Colonoscopy with endoclip application

    Coding Clinic, Third Quarter 2011 Page: 11 Effective with discharges: September 23, 2011


    Question:



    The patient underwent colonoscopy with polypectomy via snare. The polyps were removed and “three endoclips were placed” at the polypectomy site. How should this procedure be coded?



    Answer:



    Assign code 45.42, Endoscopic polypectomy of large intestine. The placement of the endoclips is inherent to the polypectomy and would not be coded separately. Endoclip placement provides mechanical hemostasis to prevent post polypectomy bleeding. In the case of post polypectomy hemorrhage, a radiopaque endoscopic clip can be used as a marker to target angiographic therapy.



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    Angela Susott
    Coding Compliance Auditor



  • 10.  RE: PCS - hemoclipping of AVM in the stomach

    Posted 03-12-2016 16:59

    We wrote to AHIMA Code-Check regarding APC cautery of an AVM of the duodenum.  For the clipping, I wrote to Coding Clinic a few months back and no response as of yet.

    Question Response:
    The recommended code assignment for APC cautery, AVM of the duodenum is:
    0D598ZZ Destruction of Duodenum, Via Natural or Artificial Opening Endoscopic

    Rationale for recommended code assignment:
    The character 3 root operation and character 4 body part are assigned based on the procedure documenation specified as:
    • APC cautery (char 3 root operation) was used to obliterate the AVM without further induction of bleeding
    • In the second duodenum (character 4 body part) near the papilla was an AVM that was bleeding,
    Destruction—Root operation 5
    Definition: Physical eradication of all or a portion of a body part by the direct use of energy, force or a destructive agent

    Reference:
    FY2016 ICD-10-PCS Reference Manual. page 43


    Thanks,


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    Christine Crockford
    Coding Reviewer



  • 11.  RE: PCS - hemoclipping of AVM in the stomach

    Posted 22 days ago
    Have you received a response from coding clinic to this question?

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    Julie, CDIP, CCS


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  • 12.  RE: PCS - hemoclipping of AVM in the stomach

    Posted 21 days ago
    I would think this would go to the root operation "Control"  0W3P8ZZ, Control bleeding in gastrointestinal tract, via natural or artificial opening endoscopic per coding clinic advice 4Q 2017 pg 105

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    Karen Neal
    Coding Quality Auditor
    Conifer Health Solutions
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