March 27, 2018

C&M Meeting, Part I: The Latest Update on Procedure Code Proposals

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The ICD-10 code set is growing, and feedback from the medical community on the changes is needed.

This is the first in a series of articles encompassing a review of the Coordination and Maintenance Committee meeting, which was held March 6 and 7, 2018. First, we will review the procedure code proposals, as the comments on these proposals are due April 6, 2018 and are scheduled for implementation, if accepted, for Oct. 1, 2018.

The URL for the meeting materials and webcast recordings are listed below. Comments on procedures should be emailed to . When commenting, consider the current documentation as well as the meaningfulness of the resulting data.

There were no requests for new diagnosis codes for public health issues or new procedure codes for New Technology Add-On Payment (NTAP) for implementation by April 1, 2018.

 

Irreversible Electroporation (IRE)

IRE is performed to destroy liver and pancreas cancer cells. This tissue ablation technique could be used in other areas, but for now the focus is on these two organs only. The benefit of this technique is that it only affects the cell membrane and does not damage healthy tissue.  

This topic was originally presented in March 2015. The request is to add new qualifiers to Table 0F5. The qualifiers proposed are F (irreversible electroporation), G (radio frequency), H (microwave), and J (cryotherapy). The Centers for Medicare & Medicaid Services (CMS) recommendation is to get public input.

 

Cell Suspension Autografting

This is a procedure for large wounds. This procedure consists of harvesting a split thickness skin sample of healthy tissue and creating a cell suspension, which is applied to the skin. The proposal included two new options: the first is to add a qualifier to table 0HR of two (partial thickness, cell suspension). The second proposal is the creation of a new technology code with a new device/substance/technology option of L (autologous epithelial cell suspension). A NTAP application has not been submitted. The CMS recommendation is to get public input.

 

Insertion of the Remedē® Phrenic Nerve Stimulation System

This is an implantation of a nerve stimulator to treat moderate to severe central sleep apnea. The device consists of an implantable pulse generator, sensing lead, stimulation lead, and patient programmer. The generator is implanted into the submuscular or subcutaneous chest region. The sensing lead is inserted into the azygos vein, with the stimulation lead inserted into right innominate (brachiocephalic) or left pericardiophrenic veins. The closest body part to the pericardiophrenic vein is the left innominate vein.  

The proposal includes an option of adding a new qualifier of 0 (pericardiophrenic vein) to Table 05H. Another option is to create a new technology code to capture the generator. The CMS recommendation was to have input before making a final decision.

 

Endovascular Bypass of Lower Extremity Arteries

This includes two new devices – LimFlow and DETOUR. The LimFlow device has received investigational device exception (IDE) approval from the Federal Drug Administration (FDA), but not full approval. The DETOUR device has received conditional IDE approval. An NTAP application may be submitted for 2020. The LimFlow endovascular procedure involves inserting overlapping stents from the vein through the artery-vein connection. The DETOUR technology reroutes blood flow from the superficial femoral artery into the femoral vein and back to the popliteal artery. The proposals included creating a new technology table, X21, which included the device value combined with lower vein and the percutaneous approach. The other option creates new body part values for right anterior tibial artery (P), left anterior tibial artery (Q), right posterior tibial artery (R), and left posterior tibial artery (S). The CMS recommendation was to utilize the current codes.

 

Implantation of Multi-Function Networked Prosthesis

This is performed to restore functional movement in the arm and/or trunk for patients who have experienced a cervical and/or thoracic level spinal cord injury. This device includes multiple pulse generators, a power source, and multiple tissue-contracting electrodes, with at least one recording module connected to one or more recording electrodes. There were two options proposed, with the first continuing to use the current codes. The second option was to create two new tables (XHH and XWH) in new technology for the insertion of the device. Two or more codes would be required to fully code this procedure, as most patients have insertions to the trunk and upper extremity. The NTAP application is being considered for 2020. The CMS recommendation was not to create the new codes.

 

Partial Knee Joint Replacement, Femoral Modular Head, and Articulating Spacer for Hip and Knee Joint

This was a proposal add new device values. For partial knee joint replacement, the proposal was to revise synthetic substitute, unicondylar to synthetic substitute, unicondylar lateral; and add synthetic substitute, unicondylar medial and synthetic substitute patellofemoral to the replacement table (0SR) and removal table (0SP). For the modular femoral head proposal, the additional of the device, modular head, was suggested to supplement and removal tables 0SU and 0SP. An additional device character was suggested for the articulating spacer for hip and knee joint proposal. The device character was proposed for the 0SR and 0SP tables, with no changes made for the spacer device. There is no NTAP application, and CMS’s recommendation was to include these new devices in all of the tables referenced in order to improve the tracking of outcomes for the devices.

 

Endovascular Thrombectomy of Intracranial and Extracranial Arteries

This issue was presented in March 2017, and there is no NTAP application. The FDA has approved the devices. The issue that prompted the submission of this proposal is that there is no data that differentiates the stent retriever thrombectomy from direct aspiration thrombectomy as it pertains to effectiveness for treating strokes. The stent retriever thrombectomy involves the use of a special catheter to remove the clot. It is important to note that there is no stent that remains after the procedure. The device is called a stent retriever because it looks like a stent.   

Direct aspiration thrombectomy removes the clot by using a large bore catheter. There is no device that remains after this procedure. In some situations, a combination of stent retriever and aspiration thrombectomy techniques could be used, reducing the potential for fragmentation of the clot. There are two options proposed for these procedures, with the first to make no changes. The second option is to add a qualifier of stent retriever to the 03C table. The CMS recommendation was to add the qualifier to table 03C.

 

Robotic Water Resection of Prostate

This is a procedure to treat benign prostatic hypertrophy (BPH). FDA approval was granted in December 2017 for this technique. This procedure is also known as aquablation therapy, and is performed with robotic assistance and ultrasound image guidance. A NTAP has been submitted for 2019. The proposal includes two options, with the first not creating a new code. The second option includes the creation of a new code in new technology with a new device/substance/technology of robotic waterjet ablation. The CMS recommendation is to create the new technology code.

 

The Administration of Plazomicin

This an infusion of antibiotics that treats carbapenem-resistant enterobacteriaceae (CRE) organisms. CRE is a gram-negative organism that is resistant to multiple drugs. This antibiotic is infused over a period of time and is used to treat complicated urinary tract infections and bloodstream infections. There were two proposals presented for the coding of this infusion, including utilizing the current codes of 3E03329 and 3E04329 or the development of a code in the new technology section, with the drug added as a new device/substance/therapeutic value. This has not been approved by the FDA, but a NTAP application has been submitted for 2019.  

 

Percutaneous Extracorporeal Membrane Oxygenation (ECMO)

ECMO is a technique used to support patients who suffer from reversible cardiopulmonary insufficiency. This technique oxygenates tissue and organs while the heart has stopped. This technique can be performed percutaneously to treat refractory cardiogenic shock until a left ventricular assistant device can be inserted.     

There are two types of percutaneous ECMO – VA (arterial and venous femoral insertion) and VV (venous insertions). VA provides respiratory and circulatory support, while VV is for respiratory support only. This approach has mostly been used for children, but there has been an increase in use among the adult population. The proposals presented include creating no new codes and adding codes into Table 5A1.   

There was much discussion regarding the body systems to include in the code development, as well as concern regarding whether the coder will be able to determine the type of percutaneous ECMO that is performed. The CMS recommendation is to continue coding the procedure using 5A15223.

 

Spinal Fusion with Hydroxyapatite Enhanced Interbody Fusion Device

This is the spinal fusion procedure using an enhanced PEEK interbody fusion device, which consists of radiolucent hydroxyapatite. This new substance will bond with the bone and reduce migration of the spinal fusion device. There are three options presented for this proposal, which include continuing with current coding (utilizing codes from Tables 0RG and 0SG), developing a new device value for tables 0RG and 0SG, or creating a new code in the new technology section, which would include a new device/substance/technology value. The CMS recommendation is the last option. The device has been approved by the FDA, but the NTAP application has not been submitted.

 

Administration of GIAPREZATM

This includes the administration of a human angiotensin vasoconstrictor for septic or other distributive shock. There are current codes (3E033XZ and 3E043XZ) that identify the administration of a vasopressor. The second option for this proposal includes the development of a code in the new technology section, which would include a new device for synthetic human angiotensin II. The FDA has approved this substance, and a NTAP was submitted for 2019. The CMS recommendation is to develop a new code in the new technology section.

 

Transfer of Prepuce for Reconstruction

This is a procedure used to treat urogenital anomalies. The issue is that for the current table, 0HX, the body part value “A” was revised from skin, genitalia to skin, inguinal for 2018 ICD-10-PCS. This body part was utilized in the coding of the transfer of skin and foreskin (prepuce) for these procedures. The root operation of transfer is missing from the male reproductive system section (0V). These procedures are now being coded using codes from tables 0VQ (Male Reproductive, Repair) and 0TQ (Urinary, Repair). The presented options included using the current codes or creating a new table in the male reproductive section for the root operation of transfer. There was much support for the creation of the new table (0VX) by CMS as well as the attendees.  

The remainder of the procedure presentation included a review of the Index and Table addendums. There was also a discussion on the life cycle of the X section codes. The X section was created for new technologies that are not usually captured by coders for inpatient coding and for new technologies that do not have the specificity required to identify the procedure for the New Technology Add-on Payment (NTAP). The NTAP is typically is in place for two to three years. There was much discussion regarding who has the responsibility to retire the X codes and move them to the Medical and Surgical section, or if we need to retire the X codes after the NTAP has been exhausted. 

It is obvious that ICD-10-PCS is growing. The coding community will have to develop a method to manage it, as well as the life cycle of the inpatient procedure codes. Remarks regarding the proposals are encouraged. The ICD-10-PCS remarks can be sent to and are due by April 6, 2018.

Program Note

Listen to Laurie Johnson today on Talk Ten Tuesdays at 10-10:30 a.m. EST as she reports on the outcome of the recent C&M meeting.


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Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer

Laurie M. Johnson, MS, RHIA, FAHIMA is currently a senior healthcare consultant for Revenue Cycle Solutions, based in Pittsburgh, Pa. Laurie is an American Health Information Management Association (AHIMA) approved ICD-10-CM/PCS trainer. She has more than 35 years of experience in health information management and specializes in coding and related functions. She has been a featured speaker in over 40 conferences. Laurie is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.

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