June 29, 2015

Here’s My PCS Pet Peeve. What’s Yours?


Do you have pet peeves? I have many, including those sun-catchers that folks hang on their rear-view mirrors, which on a sunny day blind the drivers behind them.

So, what is my PCS pet peeve? Let us discuss the root operations of restriction and occlusion. By PCS definition, “restriction” refers to the partialclosing of an orifice or tubular body part that includes both intraluminal and extraluminal methods.


In the example of a Nissen fundoplication, coding the approach to restriction makes sense because the fundus of the stomach is wrapped around the distal esophagus and sewn into place, which serves as treatment for gastroesophageal reflux disease (GERD) and hiatal hernia. The surgery strengthens the lower esophageal sphincter (between the esophagus and stomach), which stops acid from backing up into the esophagus, easily allowing the esophagus to heal.

Now we come to my problem with PCS assignment of restriction as the root procedure to craniotomy with occlusion of cerebral aneurysm (rather than the root operation of occlusion). There are two main options to treat brain aneurysms; they are open surgical clipping and endovascular therapy coiling. A cerebral aneurysm is a bulging weakened area in the wall of an artery in the brain, resulting in an abnormal widening or ballooning of the artery. Because of the weakened area in the artery wall, there is a risk for rupture of the aneurysm. With open surgical clipping, an incision is made into the skin over the head and then an opening is made into the bone with dissection down to the aneurysm at the point where it arises from the blood vessel. Placement of a metal clip across the neck of the aneurysm isolates the aneurysm from the rest of the circulatory system by blocking blood flow. This prevents the blood from entering the aneurysm, thereby preventing rupture. Often a neurosurgeon may perform a mini-craniotomy or even an eyebrow incision to clip the aneurysm. Any of these procedures are still invasive and the patient takes longer to recover than from a coiling procedure.

Most endovascular coiling procedures are done by a neurointerventional surgeon. A coiling procedure is a minimally invasive procedure that is performed as an extension of the angiogram. A catheter is inserted into the femoral artery and then threaded to the brain vasculature and into the aneurysm via flouroscopy, where platinum coils are then packed into the aneurysm up to the point where it arises from the blood vessel. The coils induce embolization, thereby preventing blood from entering the aneurysm, avoiding rupture. Additionally, a stent or balloon may be necessary to help keep the coils in place inside the aneurysm.

With either procedure, the intent is to prevent blood flow back into the aneurysmal sack, which would cause a rupture.

Occlusion, by PCS definition, is the complete closing of an orifice or lumen of a tubular body part that includes both intraluminal and extraluminal methods. Per Centers for Medicare & Medicaid Services (CMS) guidelines, the suggested coding of a cerebral artery aneurysm with a clip is 03VG0CZ, whereas the suggested coding of the coiling procedure is 03LG3DZ (percutaneous approach via femoral artery). So my question would be this: why is each of the above root operations coded differently?


Using surgical logic, I would code the cerebral aneurysm clipping as 03LG0CZ, because the intent of the clip is to occlude and not restrict the arterial flow; otherwise, rupture would certainly occur.

In fairness, there is recommended literature indicating that the coder should thoroughly research the procedure technique as well as perform a careful review of the operative report before assignment of the final code is made.

In conclusion, never assume that because there are numerous examples of particular procedures that the code assignment suggested fits all subsequent surgical cases that you might encounter in coding.



Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Denise M. Nash, MD, CCS, CIM

Denise M. Nash, MD, CCS, CIM, serves as vice president of compliance and education for MiraMed Global Services and as such she handles all Compliance and Education needs including migration to ICD-10. She has more than 20 years experience in the healthcare industry. Dr. Nash has worked for CMS in hospital auditing and has expertise in negotiation and implementation of risk contracting for managed care plans. She has also worked with individuals as well as physician groups on utilization and PQRS management to improve financial performance for the risk-based contracts and value based purchasing (VPB) programs. Her past experience also included consulting for the Office of the Inspector General of New Hampshire in its Fraud and Abuse Division.

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