Coronary Arteries: Number of Vessels/Number of Stents

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3 Coronary Arteries: Number of Vessels/Number of Stents Issue Should code table 027 be revised to capture the number of coronary vessels treated and/or the number of coronary stents inserted? New Technology Application No Background Since FY 2006, ICD-9-CM has had adjunct codes to identify the number of vessels treated in a procedure ( ) as well as the number of vascular stents inserted ( ). As intended, it has been useful to collect this data for outcomes analysis and also to adequately capture hospital resource use. It is also notable that the impetus to create these codes arose from a discussion in the FY 2005 HIPPS final rule (69 Federal Register 48974) on the need to identify insertion of stents in multiple vessels or insertion of multiple stents. ICD-10-PCS, however, does not contain adjunct codes. Instead, ICD-10-PCS users must currently make assumptions about the number of vessels and stents from the Body Part for coronary artery "site" in code table 027-Dilation of Heart and Great Vessels. However, the only assumptions possible with the current code structure are too broad, and do not accurately capture the number of coronary vessels and stents. Precisely because they are inaccurate, Coding Clinic (4th Q 2005) has also advised coders not to make these types of assumptions. Coding Options The current code table 027 is below: Section; 0 Medical and Surgical Body System: 2 Heart and Great Vessels Operation: 7 Dilation: Expanding an orifice or the lumen of a tubular body part Body Part Approach Device Qualifier 0 Coronary Artery, One Site 1 Coronary Arteries, Two Sites 2 Coronary Arteries, Three Sites 3 Coronary Arteries, Four or More Sites T Intraluminal Device, Radioactive

4 There are several options for capturing the number of coronary vessels, capturing the number coronary of stents, or capturing both. Number of coronary vessels Capturing the number of coronary vessels involves changes to the characters for Body Part in code table 027. Currently, the coronary arteries are classified by the number of distinct "sites" treated, rather than by the anatomic name of each coronary artery or the number of coronary arteries. Anatomic name Using the anatomic name of each coronary artery as the body part would lead to an unwieldy profusion of codes and is not presented as an option. Number of coronary vessels Classifying by the number of coronary arteries will limit the number of codes while allowing for a direct count of the number of vessels. This type of classification is already familiar to coders and, with corresponding guidelines on which specific coronary vessels to count, will be unambiguous. In addition to code table 027, there are three other code tables in Body System 2-Heart and Great Vessels which use coronary arteries as a Body Part. They are: code table 021-Bypass; code table 02C-Extirpation; and code table 02Q-Repair. Defining the Body Part by the number of coronary arteries rather than by "site" does not disrupt use of these other tables. Also, the ICD-9-CM precedent for Bypass already makes using the number of coronary arteries familiar to coders. No changes Because the primary focus is on stents, leaving the Body Part unchanged may simplify the revisions. This would also leave tables 021, 02C and 02Q unchanged. Number of coronary stents Capturing the number of coronary artery stents can be accomplished by revising the Device character or the Qualifier character in code table 027. These changes allow a direct count. Device character The existing Device values for "intraluminal device, drug-eluting" and "intraluminal device" describe drug-eluting stents and bare metal stents. By adding Device values that are currently open in Body System 2- Heart and Great Vessels, the Device character can be expanded to show the number of stents. This adheres to the ICD-10-PCS principle of describing devices within the Device column while also allowing for the bifurcation qualifier to be appended to the resulting procedure codes.

5 Existing device values 4-intraluminal device, drug-eluting and D-intraluminal device are left unchanged. This allows these values to be assigned for one stent and when the number of stents is unspecified. It also allows these existing values to be assigned when collecting the number of stents is not applicable, for example in other code tables in Body System 2-Heart and Great Vessels which also use Device values 4-intraluminal device, drug-eluting and D- intraluminal device. These other code tables are: 021-Bypass, 02H-Insertion, 02L-Occlusion, 02P-Removal, 02V-Restriction, and 02W-Revision. As proposed, expanding the Device character to show the number of stents would be limited to code table 027-Dilation. However, if it was later seen as desirable to collect the number of intraluminal devices for one or more of these other code tables, the structure proposed for code table 027 could easily be adopted. Qualifier character Rather than altering the Device values, the number of stents can be shown by expanding the Qualifier values. This limits the revisions to code table 027, rather than crossing over to other code tables. It also allows the use of language already familiar to coders from ICD-9-CM and differentiates stents from any other intraluminal devices. Finally, it conserves Device values that may be needed in the future. However, this option means that a single code could not be assigned that identifies both the number of stents and bifurcation, because both are shown by qualifiers. A second code could be assigned for bifurcation, but this could complicate data analysis. Alternately, bifurcation could simply not be identified in these cases. Option 1 - Number of coronary vessels and stents (Device character) Section: 0 Medical and Surgical Body System: 2 Heart and Great Vessels

6 Operation: 7 Dilation: Expanding an orifice or the lumen of a tubular body part Body Part Approach Device Qualifier 0 Coronary Artery, One 1 Coronary Arteries, Two 2 Coronary Arteries, Three 3 Coronary Arteries, Four or More 5 Intraluminal Device, Drug-eluting, Two 6 Intraluminal Device, Drug-eluting, Three 9 Intraluminal Device, Drug-eluting, Four or More E Intraluminal Device, Two F Intraluminal Device, Three G Intraluminal Device, Four or More T Intraluminal Device, Radioactive Option 2 - Number of coronary vessels and stents (Qualifier character) Section: 0 Medical and Surgical Body System: 2 Heart and Great Vessels

7 Operation: 7 Dilation: Expanding an orifice or the lumen of a tubular body part Body Part Approach Device Qualifier 0 Coronary Artery, One 1 Coronary Arteries, Two 2 Coronary Arteries, Three 3 Coronary Arteries, Four or More Option 3 - Number of coronary stents only (Device character) T Intraluminal Device, Radioactive 1 Insertion of one vascular stent/ unspecified number of stents 2 Insertion of two vascular stents 3 Insertion of three vascular stents 4 Insertion of four or more vascular stents Section: 0 Medical and Surgical Body System: 2 Heart and Great Vessels

8 Operation: 7 Dilation: Expanding an orifice or the lumen of a tubular body part Body Part Approach Device Qualifier 0 Coronary Artery, One Site 1 Coronary Arteries, Two Sites 2 Coronary Arteries, Three Sites 3 Coronary Arteries, Four or More Sites 5 Intraluminal Device, Drug-eluting, Two 6 Intraluminal Device, Drug-eluting, Three 9 Intraluminal Device, Drug-eluting, Four or More E Intraluminal Device, Two F Intraluminal Device, Three G Intraluminal Device, Four or More T Intraluminal Device, Radioactive Option 4 - Number of coronary stents only (Qualifier character) Section: 0 Medical and Surgical Body System: 2 Heart and Great Vessels

9 Operation: 7 Dilation: Expanding an orifice or the lumen of a tubular body part Body Part Approach Device Qualifier 0 Coronary Artery, One Site 1 Coronary Arteries, Two Sites 2 Coronary Arteries, Three Sites 3 Coronary Arteries, Four or More Sites T Intraluminal Device, Radioactive 1 Insertion of one vascular stent/ unspecified number of stents 2 Insertion of two vascular stents 3 Insertion of three vascular stents 4 Insertion of four or more vascular stents

10 Peripheral Arteries: Number of Stents and Bifurcation Issue Should code tables 037 and 047 be revised to capture the number of stents inserted and to capture treatment of vessel bifurcations? New Technology Application No Background As with coronary arteries, ICD-10-PCS does not provide a means to identify the number of peripheral vessels treated in a procedure or the number of peripheral stents inserted. For peripheral, it's less essential to change the code table to capture the number of vessels treated. This is because, for the most part, ICD-10-PCS enumerates peripheral vessels individually by name and often by laterality as well. Even when it doesn't, ICD-10-PCS guidelines state that the same code is assigned multiple times for interventions in different vessels that use the same body part (eg, because the common femoral artery, external femoral artery and superficial femoral artery all use the body part Femoral Artery, the same code would be assigned three times for dilation of all three vessels during the same encounter). So it is possible to capture the number of vessels with reasonable accuracy by totaling the number of codes assigned. However, the number of peripheral stents inserted cannot be accurately captured without changes to code tables 037-Dilation of Upper Arteries and 047-Dilation of Lower Arteries. Further, although available in ICD-9-CM and present on coronary artery Dilation table 027, the ability to identify treatment of a vessel bifurcation is not currently possible for peripheral artery Dilation tables 037 or 047. Restoring this information will allow data collection at the current level of detail and will also provide consistency between coronary and peripheral arteries within ICD-10-PCS. Coding Options The changes being requested for peripheral vessels allow a direct count of stents, rather than assumptions. Directly counting the number of stents is already familiar to coders in ICD-9-CM. Number of peripheral artery stents Capturing the number of peripheral stents can be accomplished by the same options in the Device and Qualifier characters for peripheral artery code tables 037 and 047 as are being proposed for coronary artery code table 027.

11 Device character The same device values proposed for coronary artery table 027 are also open in Body System 3-Upper Arteries and Body System 4-Lower Arteries. Using the same values maintains consistency throughout the classification. As with the coronary artery proposal, existing device values 4-intraluminal device, drug-eluting and D-intraluminal device are left unchanged. These values can be assigned for one stent and when the number of stents is unspecified. They can also be assigned when the number of stents is not applicable for other code tables which use the intraluminal device values: 03H and 04H-Insertion, 03L and 04L-Occlusion, 03P and 04P-Removal, 03V and 04V-Restriction, and 03W and 04W-Revision. Qualifier character Again, using Qualifier values to show the number of stents limits the impact to code tables 037 and 047, uses language already familiar to coders, differentiates stents from other intraluminal devices, and conserves Device values. However, a single code could not identify both the number of stents and bifurcation, because both are shown by qualifiers. Bifurcation Similar to coronary artery table 027, a Qualifier for bifurcation would be added to peripheral artery tables 037 and 047. If the number of stents is also shown by a Qualifier, as in Option 2, either a second code could be assigned for bifurcation, or bifurcation could simply not be identified in these cases. Option 1 - Number of peripheral stents (Device character) and bifurcation (Qualifier) Section: 0 Medical and Surgical Body System: 4 Lower Arteries Operation: 7 Dilation: Expanding an orifice or the lumen of a tubular body part Body Part Approach Device Qualifier 0 Abdominal Aorta 1 Celiac Artery 2 Gastric Artery 3 Hepatic Artery 4 Splenic Artery 5 Superior Mesenteric Artery 6 Colic Artery, Right 7 Colic Artery, Left 8 Colic Artery, Middle 9 Renal Artery, Right A Renal Artery, Left B Inferior Mesenteric Artery C Common Iliac Artery, Right D Common Iliac Artery, Left 5 Intraluminal Device, Drug-eluting, Two 6 Intraluminal Device, Drug-eluting, Three 9 Intraluminal Device, Drug-eluting, Four or More E Intraluminal Device, Two F Intraluminal Device, Three G Intraluminal Device, Four or More

12 Option 2 - Number of peripheral stents (Qualifier character) and bifurcation (Qualifier) Section: 0 Medical and Surgical Body System: 4 Lower Arteries Operation: 7 Dilation: Expanding an orifice or the lumen of a tubular body part

13 Body Part Approach Device Qualifier 0 Abdominal Aorta 1 Celiac Artery 2 Gastric Artery 3 Hepatic Artery 4 Splenic Artery 5 Superior Mesenteric Artery 6 Colic Artery, Right 7 Colic Artery, Left 8 Colic Artery, Middle 9 Renal Artery, Right A Renal Artery, Left B Inferior Mesenteric Artery C Common Iliac Artery, Right D Common Iliac Artery, Left 1 Insertion of one vascular stent/ unspecified number of stents 2 Insertion of two vascular stents 3 Insertion of three vascular stents 4 Insertion of four or more vascular stents

14 Coronary and Peripheral Artery Extirpation: Bifurcation Issue Should coronary code table 02C and peripheral artery code tables 03C and 04C be revised to capture treatment of vessel bifurcations? New Technology Application No Background Since FY 2007, ICD-9-CM has had adjunct code to identify treatment of vessel bifurcation. This has been useful for data collection and analysis as well explaining hospital resource use. In ICD-9-CM usage, bifurcation code can be used with primary codes for angioplasty, stent insertion and atherectomy. In ICD-10-PCS, bifurcation is only currently available as a Qualifier for code table 027- Dilation of Heart and Great Vessels. A Qualifier for bifurcation has been separately requested for code tables 037-Dilation of Upper Arteries and 047-Dilation of Lower Arteries. This request is to add a Qualifier for bifurcation to the codes tables for coronary and peripheral artery Extirpation. Doing so will restore the ability to capture treatment of vessel bifurcations for atherectomy (Extirpation) in addition to angioplasty and stenting (Dilation). Coding Options Add a Qualifier for bifurcation to code tables 02C, 03C and 04C. Code Table 02C-Extirpation of Heart and Great Vessels Section; 0 Medical and Surgical Body System: 2 Heart and Great Vessels Operation: C Extirpation: Taking or cutting out solid matter from a body part Body Part Approach Device Qualifier

15 0 Coronary Artery, One Site 1 Coronary Arteries, Two Sites 2 Coronary Arteries, Three Sites 3 Coronary Arteries, Four or More Sites T Intraluminal Device, Radioactive Code Table 03C-Extirpation of Upper Arteries Section: 0 Medical and Surgical Body System: 3 Upper Arteries

16 Operation: C Extirpation: Taking or cutting out solid matter from a body part Body Part Approach Device Qualifier 0 Internal Mammary Artery, Right 1 Internal Mammary Artery, Left 2 Innominate Artery 3 Subclavian Artery, Right 4 Subclavian Artery, Left 5 Axillary Artery, Right 6 Axillary Artery, Left 7 Brachial Artery, Right 8 Brachial Artery, Left 9 Ulnar Artery, Right A Ulnar Artery, Left B Radial Artery, Right C Radial Artery, Left D Hand Artery, Right F Hand Artery, Left G Intracranial Artery H Common Carotid Artery, Right J Common Carotid Artery, Left Code Table 04C-Extirpation of Lower Arteries

17 Section: 0 Medical and Surgical Body System: 4 Lower Arteries Operation: C Extirpation: Taking or cutting out solid matter from a body part

18 Body Part Approach Device Qualifier 0 Abdominal Aorta 1 Celiac Artery 2 Gastric Artery 3 Hepatic Artery 4 Splenic Artery 5 Superior Mesenteric Artery 6 Colic Artery, Right 7 Colic Artery, Left 8 Colic Artery, Middle 9 Renal Artery, Right A Renal Artery, Left B Inferior Mesenteric Artery C Common Iliac Artery, Right D Common Iliac Artery, Left E Internal Iliac Artery, Right F Internal Iliac Artery, Left H External Iliac Artery, Right