Use Your PCS Resources Fully

By Cathie Wilde, RHIA, CCS – Director of Coding Services, Medical Record Associates, LLC

Appendix D: Body Part Key of the ICD-10-PCS Handbook can play an important role in correct code assignment and appropriate reimbursement. The following example demonstrates effective use of the Body Part Key.

The patient is a 55 year old female admitted with melena. An esophagogastroduodenoscopy is performed with the finding of a single cratered 5 cm ulcer in the duodenum just beyond the duodenal bulb. There were multiple areas with mild oozing but none were amenable to cauterization or clipping. Plan to discuss empiric gastroduodenal artery embolization with interventional radiology given no area to treat endoscopically and high risk of ongoing bleeding. 

The patient was taken to the interventional radiology suite where the following procedure was performed. Using fluoroscopic guidance, the right common femoral artery was punctured using a micropuncture set at the level of the mid-femoral head. A 0.018 wire was passed easily into the vessel lumen. A small skin incision was made over the needle. Then the inner dilator and wire were removed and a Betson wire was advanced under fluoroscopy into the aorta. The micropuncture sheath was exchanged for a 5 French sheath which was attached to a continuous heparinized saline side arm flush.

The Glidewire was advanced into the right hepatic artery and the C2 glide catheter was advanced into the common hepatic artery. The wire was removed and a small contrast injection was utilized to confirm appropriate position and identify the gastroduodenal artery (GDA). Next, a STC micro catheter and double angled Guidewire were utilized to select the GDA. Multiple Hilal coils (7) were placed throughout the course of the GDA. Gel-Foam was intermittently administered between deployment of the coils. Finally, the most proximal component of the GDA was embolized using a Concerto coil. No discrete evidence of active extravasation noted arising from the branches of the GDA. Successful coil embolization of the gastroduodenal artery. 

As the blood supply to the vessel was effectively cut off, the correct root operation for the embolization is ‘occlusion’. Review of the ICD-10-PCS alphabetic index under occlusion reveals no choice for gastroduodenal artery. However, there is an option for gastric artery. So the coder selects this site for assignment of the PCS code assuming the gastroduodenal artery must be part of the gastric artery. The following code assignments are made with the resulting FY 2018 DRG assignment:

Diagnosis:   K26.4 Chronic or unspecified duodenal ulcer with hemorrhage

Procedure:   04L23DZ Occlusion of Gastric Artery with Intraluminal Device, Percutaneous Approach

MS-DRG:     379 G.I. Hemorrhage w/o CC/MCC

DRG wgt:    .6447

However, if the coder had referenced Appendix D: Body Part Key in the ICD-10-PCS Handbook they would find the ICD-10-PCS Value of hepatic artery for the gastroduodenal artery. Adjusting the code selection accordingly finds the following:

Diagnosis:   K26.4 Chronic or unspecified duodenal ulcer with hemorrhage

Procedure:   04L33DZ Occlusion of Hepatic Artery with Intraluminal Device, Percutaneous Approach

MS-DRG:     358 Other Digestive System O.R. Procedures w/o CC/MCC

DRG wgt:     1.4082

The resulting procedure code has only a one character value difference for the body part assignment based on effective utilization of the Body Part Key which results in a significant impact on the reimbursement implications. The case has changed from a medical to a surgical DRG under the MS-DRG system. 

Coding Clinic Third Quarter 2014, pages 26-27 also addresses the appropriate code assignment for coil embolization of the gastroduodenal artery.