Coding, Classification & Reimbursement

PCS coding for carotid andertectomy

  • 1.  PCS coding for carotid andertectomy

    Posted 23 days ago

     Hello,

    Any feedback is welcome as we are trying to figure our correct PCS coding in this scenario. If plaque is removed from the left common, left internal, and left external carotid, would PCS coding of all three (common, internal, and external) be appropriate? Or would the endarterectomy of the internal and external carotid only be reportable as this was the furthest anatomical sites from point (common carotid) of entry base on PCS coding  guidelines B4.1c. Any thoughts or feedback is welcome.

    Thanks,
    Julia



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    Julia Vang
    Him Coding Coordinator
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  • 2.  RE: PCS coding for carotid andertectomy

    Posted 22 days ago
    I got a recent response from AHA that said to code extirpation of the internal carotid artery only, but they did not explain their reasoning for not coding the external carotid. I had previously been coding the internal and external carotid artery since they were the most distal point in a tubular body part. I wonder if they are thinking the internal carotid artery is closer to the brain making it the deeper artery in that direction? I'm not comfortable sharing the letter since the bottom of it says distribution w/o their permission is prohibited.


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    Laurie Zawiskie
    Coder III
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  • 3.  RE: PCS coding for carotid andertectomy

    Posted 18 days ago
    Hi Laurie,

    Thanks so much for your response. I understand that the AHA letter can't be shared. I'm hoping coding clinic may clarify this in the future for everyone.



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    Julia Vang
    Him Coding Coordinator
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  • 4.  RE: PCS coding for carotid andertectomy

    Posted 10 days ago
    Interesting...I've always wanted to go with using internal and external since they are parallel to one another and neither would be further from the point of origin however when I sent my question in to Coding Clinic they responded to code Internal, External and Common because there wasn't any indication that the plaque was continuous.  Maybe it was just how my particular operative report was worded...I am not all that sure...but I think it is standard to for the plaque in the carotids to be all one clump.

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    Chrystel Barron, RHIA, CCS, CCS-P, CHTS-TR, CICA
    Coding Education Instructor
    Cleveland Clinic Health System
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  • 5.  RE: PCS coding for carotid andertectomy

    Posted 10 days ago
    Chrystel - That is interesting that you got a different response. I've wondered if the most distal point is what is coded on all procedures involving a tubular body part or only when it is a continuous lesion. After hearing your response, it sound like it is only coded to the most distal point on a continuous lesion. This is from the op report I sent them. Maybe they only coded the px on the internal carotid, because that's where the site of the stenosis was, although I assumed there was plaque in all 3 areas since an endarterectomy was done for each.

    He underwent a CT angio of the neck arteries.  This showed greater than 70 percent right ICA stenosis.

    An arteriotomy was made in the common carotid artery and extended through the plaque and into the internal carotid artery distally.  An 8-French Argyle carotid shunt was placed in the common and internal carotid arteries.

    An endarterectomy of the common, external, and internal carotid arteries was then performed.  The inner surface of the vessel was meticulously examined for any loose or residual atherosclerotic debris utilizing 2X loupe magnification.  Thereafter, a bovine patch was obtained and used to close the arteriotomy.


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    Laurie Zawiskie
    Coder III
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  • 6.  RE: PCS coding for carotid andertectomy

    Posted 10 days ago
    The internal carotid artery and external carotid artery branch off the common carotid artery. The only way to access the internal and external carotids is from the common carotid. Based on the operative report above and the PCS Guidelines which take precedence over Coding Clinic, an endarterectomy of the internal and external carotid arteries should be coded because they are a continuous section of a tubular body part (common carotid) and the furthest anatomical site from the point of entry (B4.1c). The common carotid endarterectomy would not be coded. See also PCS Guideline for Multiple Procedures B3.2a. wihich also applies. It does not surprise me that Coding Clinic gave out conflicting advise and that is why I follow this hierarchy for coding: 1. Instructions & conventions of the classification system; 2.Official Guidelines; 3. Coding Clinic.

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    Sheri Simoni

    Documentation and Coding Compliance Auditor
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  • 7.  RE: PCS coding for carotid andertectomy

    Posted 8 days ago
    ​Hello,

    I was very happy to see this topic brought up.  I also find the responses enlightening.  I am going to add a few comments of my own.

    In my experience, I have struggled trying to decipher the Operative documentation for these cases.  First it seems the documentation for these cases usually  states "Carotid Endarterectomy" (right or left), leaving the coder to try to decipher which of the carotid arteries were treated from the body of the report.  And the Guidelines do state to choose the site furthest from the point of entry when the lesion is "continuous".  If "continuous" or words to that effect is documented do you choose the internal or external?  Then there is the question of the new Qualifier  6 Bifurcation.  If the lesion is continuous do you use the Body Part for Common Carotid with Qualifier 6?  Does the term "bifurcation" have to be documented?

    And the "conflicting" advice from Coding Clinic is not very surprising.

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    Lawrence Barr
    President
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  • 8.  RE: PCS coding for carotid andertectomy

    Posted 8 days ago
    Lawrence,

    I'e had that question also. Do we use our knowledge of the anatomy to assign birfurcation or do we only code it when documented? I did ask if it should be assigned in my scenario. It was not assigned and they didn't address when it should be assigned. It may take several more questions to AHA to get a complete understanding of the correct way to code a carotid endarterectomy.

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    Laurie Zawiskie
    Coder III
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  • 9.  RE: PCS coding for carotid andertectomy

    Posted 7 days ago
    ​I had to go back and reread the Guideline B4.1c because I do not remember anything about a "continuous lesion". The Guideline states "If a procedure is performed on a continuous section of a tubular body part, code the body part value corresponding to the furthest anatomical site from the point of entry". Whether or not the lesion is continuous is irrelevant. I think I also remember hearing during one of the Coffee and Coding sessions when Maria was discussing a procedure on arteries with a bifurcation in the lower extremity that this particular Guideline didn't pertain to the artery she was coding since it branched off it was not a continuous section. (I would have to go back and replay the webinar though to be absolutely sure that is what she said. I think I was multitasking at the time and when I heard that it caught my attention).



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    Karen Neal, RHIA, CCS
    APPROVED I10 CM/PCS
    Coding Quality Auditor
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  • 10.  RE: PCS coding for carotid andertectomy

    Posted 7 days ago
    ​Hello,

    The following is the example from Guideline B4.1c

    Example: A procedure performed on a continuous section of artery from the femoral artery to the external iliac artery with the point of entry at the femoral artery is coded to the external iliac body part.

    Why would a procedure be performed on a "continuous section of artery" if the lesion being treated was not "contiguous"?

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    Lawrence Barr
    President
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  • 11.  RE: PCS coding for carotid andertectomy

    Posted 6 days ago
    ​The "continuous segment of a tubular body part" is giving us parameters for whether or not we would separately code a procedure, not whether it is a continuous lesion.  If it were a continuous segment, then only one procedure would be coded with the body part corresponding to the furthest anatomical site from the point of entry. However,  if it was not a continuous segment, then the procedure would be separately coded to the applicable body parts.  I did go back a listen to the replay of AHIMA Coffee and Coding-Femoral PTCA and Stent and Maria did in fact bring up this guideline (B4.1c). In the procedure she was explaining, the entire segment of the proximal anterior tibial artery extending into the proximal SFA was balloon angioplastied. She said that there would be 2 procedure codes for this-the dilation of the femoral artery as well as the anterior tibial artery because they are not a continuous tubular body parts. She stated that the anterior tibial artery is a branch off of the popliteal artery.  So in this case, there was a continuous lesion extending from the AT to the SFA, but since it was not considered a continuous section of a tubular body part, it would be coded separately.

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    Karen Neal, RHIA, CCS
    APPROVED I10 CM/PCS
    Coding Quality Auditor
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  • 12.  RE: PCS coding for carotid andertectomy

    Posted 6 days ago
    Edited by Cristina Co 6 days ago

    The external iliac artery (EIA) and common femoral artery (CFA) are a single, continuous artery in the lower extremity.  You can see that it is nicely illustrated in the picture below (in blue).

    Dr. Z Abdominal aortography and run-off

    Basically, the external iliac artery continues down the leg to become the common femoral artery. In the example provided, the lesion is located in the femoral-external section, which is normally identified as a continuous vessel.  So, it makes sense to assign a code to EIA.  The EIA is further from the point of entry than the CFA, which happens to be the puncture site.

    So, in the example provided, the precise location of the lesion within the femoral-external artery section has no bearing on the coding as long as this vessel that is being treated is normally identified as a continuous tubular body part. Unless it is a variant anatomy.

    The left common carotid artery (LCCA), left internal carotid and left external carotid would not be considered a continuous vessel as the LCCA bifurcates into internal and external.

    Really interesting that Coding Clinic has varying advices on this guideline.

    The picture is from Dr. Z's Interventional Radiology.

     



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    Cristina Co
    Outpatient Coder
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  • 13.  RE: PCS coding for carotid andertectomy

    Posted 5 days ago
    Edited by Lawrence Barr 5 days ago
    ​Hello,

    I am working on one right now.  All the OR Rept says is L Carotid Endarterectomy with patch.  The common, internal, nor external are not specified.  The entry point is not specified.  "... a very large calcified plaque" is really all that is documented.  Am I supposed to send a query to the surgeon asking for which carotid artery(ies), where is the entry point, was the bifurcation involved, and was the lesion(s) continuous?  Fortunately, the discharge summary documents the "LICA" so I am going to use that.  Or I can just expect to issue queries on just about every carotid endarterectomy I get.

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    Lawrence Barr
    President
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