Full Answer
Coronary artery bypass procedures are coded differently than other bypass procedures, which is described in guideline B3.6a. Rather than identifying the body part bypassed from, the body part identifies the number of coronary artery sites bypassed to, and the qualifier specifies the vessel bypassed from. ICD-10-PCS Guideline 3.6c.
If multiple coronary artery sites are bypassed, a separate procedure is coded for each coronary artery site that uses a different device and/or qualifier. ICD-10-PCS Guideline B3.9. If an autograft is obtained from a different body part in order to complete the objective of the procedure, a separate procedure is coded. ICD-10-PCS Guideline B4.4.
In honor of American Heart Month, this month’s Code Cracker explores the guidelines for coding heart procedures. There are a few specific guidelines associated with procedures done on the coronary arteries in ICD-10-PCS which need to be reviewed.
First, a discussion of applicable ICD-10-PCS guidelines is essential. According to the Centers for Medicare and Medicaid Services’ Official ICD-10-PCS Coding Guidelines: ICD-10-PCS Guideline B3.6b.
The small (short) saphenous vein (SSV) is located 1 cm posterior to the lateral malleolus, runs centrally up the posterior calf, and drains into the popliteal vein. As coronary artery bypass grafting (CABG) conduits, the saphenous veins have an 80-90% early patency rate, which decreases to 50% at 10 years.
Saphenous vein grafts (SVGs) are the most frequently used conduits for coronary artery bypass graft (CABG) surgery but are associated with 10-year vein graft failure (VGF) rates of 40−50%.
The variations of this surgery include:Off-pump CABG. This type of CABG doesn't use a heart-lung bypass machine. ... Minimally invasive CABG. This variation of CABG doesn't use a large incision and splitting/lifting of your sternum and rib cage. ... Robot-assisted CABG. ... Hybrid procedure.
One year after CABG, 10 to 20% of saphenous vein grafts fail [6–8]. From 1 to 5 years, an additional 5 to 10% fail, and from 6 to 10 years, an additional 20 to 25% fail [9]. Ten years after surgery, only about half of saphenous vein grafts are patent, and of those, only half are free of stenosis [10].
The use of radial-artery grafts for coronary-artery bypass grafting (CABG) may result in better postoperative outcomes than the use of saphenous-vein grafts.
thigh"The great saphenous vein is the major superficial vein of the medial leg and thigh. It is the longest vein in the human body, extending from the top of the foot to the upper thigh and groin.
During the procedure, a surgeon cuts through the breastbone and spreads the ribcage to access the heart. Open-heart surgery may include CABG (bypass surgery), heart transplant and valve replacement.
The bypass machine is necessary to pump blood while the heart is stopped. While the traditional "open heart" procedure is still commonly done and often preferred in many situations, less invasive techniques have been developed to bypass blocked coronary arteries.
There are two types of CABG operations currently available: on-pump and off-pump surgery. On-pump procedures require the surgeon to open the chest bone (sternum), stop the patient's heart, and place the patient on a heart-lung machine.
The saphenous vein (SPV) is a commonly used conduit for bypass due to the ease of harvest, which can generally be done through minimally invasive procedures, with less scarring and faster recovery. But the failure of vein grafts over the long term remains a significant problem.
The great saphenous vein's primary task is to drain deoxygenated blood from the foot, as well as superficial parts of the leg and knee (closer to the surface). This is taken back to the heart and lungs, where oxygen and nutrients are restored for delivery to the rest of the body.
You will feel the swelling in the location where the vein was treated. If the vein in the thigh was treated, your thigh will feel swollen. If the vein on the back of your calf was treated, the calf will feel swollen. The tumescent will slowly be absorbed by the evening or the next morning.
However, its durability and longevity are not ideal. One year after coronary surgery, 10% to 20% of saphenous vein grafts fail. From 1 to 5 years, an additional 5% to 10% fail, and from 6 to 10 years, an additional 20% to 25% fail.
The saphenous vein graft has the advantage of being long and easy to handle, and has been found to require less transfusion compared to the bilateral internal mammary artery. The issue with this graft is that the patency rate is not as good as that of the left internal mammary artery.
In fact, patients who have had their saphenous vein harvested for coronary bypass surgery can still have problems with varicose veins. This difficulty can occur because only part of the saphenous vein was removed for heart surgery, while the remaining part of the vessel goes on to become diseased.
It's well known in cardiac circles, says Rade, that more than half of venous grafts will be completely blocked off within 10 years after the surgery. It also turns out, according to the new Hopkins-led study results, that one in five vein grafts blocks off within six months of surgery, usually because of blood clots.
Example: Angioplasty of two distinct sites in the left anterior descending coronary artery with placement of two stents is coded as Dilation of Coronary Arteries, Two Sites, with Intraluminal Device.
B3.6b. Coronary arteries are classified by number of distinct sites treated, rather than number of coronary arteries or anatomic name of a coronary artery (e.g., left anterior descending). Coronary artery bypass procedures are coded differently than other bypass procedures as described in guideline B3.6a. Rather than identifying the body part bypassed from, the body part identifies the number of coronary artery sites bypassed to, and the qualifier specifies the vessel bypassed from.
Note: The Internal Mammary Artery = No Device. It is not considered graft material.
I mentioned two main types of CABG: aortocoronary and mammary graft. In an aortocoronary bypass, a connection is made from the aorta to the coronary artery using a free graft. That free graft can be made of arterial or venous tissue obtained from the patient (autologous), cadaver tissue (nonautologous), animal tissue (zooplastic), or synthetic material. The most common type of free graft comes from the saphenous vein from the patient’s leg. Pedicled grafts may also be used, where an artery is detached from its distal point and rerouted to the coronary arteries. This is most commonly achieved using the internal mammary arteries. It is not uncommon for a single operative session to include bypass of multiple coronary arteries using multiple devices.
Rationale: Two of the arteries were bypassed using a saphenous vein graft from the aorta. The other artery was bypassed using a pedicle LIMA graft. Since two of the arteries had a different device and qualifier than the other, two codes are necessary when we apply coding guideline B3.6c.
B3.6b: Coronary artery bypass procedures are coded differently than other bypass procedures as described in the previous guideline. Rather than identifying the body part bypassed from, the body part identifies the number of coronary arteries bypassed to, and the qualifier specifies the vessel bypassed from.
Pedicled grafts are not classified as devices in ICD-10-PCS because they remain attached to their original blood supply. For this reason, pedicled grafts are coded using the second row of the 021 table, which only has one device option, No Device.
The most common type of free graft comes from the saphenous vein from the patient’s leg. Pedicled grafts may also be used, where an artery is detached from its distal point and rerouted to the coronary arteries. This is most commonly achieved using the internal mammary arteries.
The ICD-10-PCS definition of the root operation Bypass is “altering the route of passage of the contents of a tubular body part.” In the case of the arterial system, the tubes are the arteries of the heart, as well as noncoronary circulation. The term “bypass” isn’t unique to the medical profession. We talk about bypasses in traffic or figurative bypasses at work when we develop “workarounds” to circumvent a problem. An arterial bypass is no different: there is a blockage we need to get around, and to do that, we must make a new pathway.
B3.6a: Bypass procedures are coded by identifying the body part bypassed “from” and the body part bypassed “to.” The fourth character body part specifies the body part bypassed from, and the qualifier specifies the body part bypassed to.
Patient with CAD is admitted for PTCA and stenting of 3 coronary arteries. Drug-eluting stents were placed in the RCA x 2 and LAD.
ICD-9-CM requires separate codes for the PTCA, insertion of stents, number of stents, and how many vessels are treated. ICD-10-PCS has one comprehensive code that describes the number of sites treated (not vessels) with PT CA and the type of stent used. If different devices (drug-eluting, non-drug-eluting, radioactive, or no stent) are used in one procedure, separate codes are assigned to indicate how many vessels are treated with that type of device.
Rationale: Both ICD-9-CM and ICD -10-PCS require a distinct code for the LIMA bypass. The aorto-coronary bypasses are coded differently in ICD-9-CM vs. ICD-10-PCS with ICD-10-PCS requiring separate codes for the different types of devices (i.e., autologous artery, autologous vein). The cardiopulmonary bypass is coded similarly in both code sets. ICD-10-PCS also requires separate codes for the harvesting of the bypass grafts, which are coded with the root operation Excision since only a portion of the artery/vein was removed.
The 2022 edition of ICD-10-CM Z95.1 became effective on October 1, 2021.
Z77-Z99 Persons with potential health hazards related to family and personal history and certain conditions influencing health status