2020 ICD-10-PCS Guideline Changes: Make Room for Exceptions

2020 ICD-10-PCS Guideline Changes: Make Room for Exceptions

On April, we provided an overview of the upcoming ICD Code Revisions for FY2020. In July, we detail the 2020 Proposed Rule for the Inpatient Prospective Payment System (IPPS) CMS-1716-P, which was available in the Federal Register, May 3, 2019. This years’ updates to the ICD-10-PCS Official Guidelines for Coding and Reporting include a new section. Additionally, there are updates to an existing section, new guidance on a body part. And some editorial changes and the introduction to the possibility of exceptions for special cases.  In addition, the Guideline changes also included exceptions regarding mastectomy procedures, followed by immediate reconstruction; a welcomed change.

Stay current with all the ICD-10-CM/PCS coding updates by signing up for our YES Education webinars. Our Subscription Bundles offer 12-month access to practical, focused coding updates education for one annual fee. For information regarding the ICD-10-PCS FY 2022 coding updates and the FY 2022 IPPS Final Rule, review our article, “CMS Releases FY 2022 ICD-10-PCS Code Updates Files.” You can find further information on these guidelines and a comprehensive review of all of the changes for ICD-10-PCS in the ICD-10 Updates collection by YES HIM Education.

The Exceptions:  Mastectomies Coded in All Circumstances- Immediate Replacement Included

The Introduction includes this new line regarding the guidelines. “They are intended to provide direction that is applicable in most circumstances.  However, there may be circumstances where exceptions are applied.”

• A dilemma solved for coding professionals. The updated guidelines include the exceptions that involve a mastectomy followed by immediate reconstruction. Timing determines whether the coder reports the mastectomy. If a patient had a mastectomy during the current encounter and a subsequent reconstruction at a different episode. Then the coder reports mastectomy for the first encounter, and the reconstruction for the next one. This was different in the case of a mastectomy then an immediate reconstruction during the same encounter.  Before 2020, following the guidelines meant that in the case of immediate replacement. The coder would not code the mastectomy as it was necessary to remove the native breast first before replacing it.  The exceptions to the guidelines give coding professionals a solution to this dilemma. They also bring the guidelines in line with the advice published in the Third Quarter 2018 Coding Clinic page 13, in the article. Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction: mastectomy is coded separately, and the harvest of the DIEP graft is not reflected in a separate code.

Additional Exceptions

• Guideline B3.1b saw updates. It states that Components of a procedure specified in the root operations definition or explanation. As integral to that root operation are not coded separately. The exception is listed:  Exceptions: Mastectomy followed by breast reconstruction, both resection and replacement of the breast are coded separately. This contrasts the resection of the native breast before replacement to the example given in the guideline: Resection of a joint as part of a joint replacement procedure is included in the root operation definition of Replacement and is not coded separately. As noted in the Third Quarter 2018 Coding Clinic article, “Mastectomy with breast replacement/reconstruction and joint replacement surgery are conceptually very different. In joint replacement, the objective is to restore function by replacing the joint. For a mastectomy with reconstruction, it is important to identify that the primary objective of the surgery. To remove cancerous or potentially cancerous breast tissue, and that the reconstruction is an additional objective.”

More Exceptions

• The changes in guideline B3.9 also relate to these circumstances. 9 instructs that if an autograft is obtained from a different procedure site in order to complete the objective of the procedure, a separate procedure is coded.  It highlights excision of a saphenous vein for a coronary bypass as an example.
• The updated guideline lists the exception to this guideline. Except when the seventh character qualifier value in the ICD-10-PCS table fully specifies the site from which the autograft was obtained.
• Added to the saphenous vein example is the following: Replacement of breast with autologous deep inferior epigastric artery perforator (DIEP) flap, excision of the DIEP flap is not coded separately. The seventh character qualifier value Deep Inferior Epigastric Artery Perforator Flap in the Replacement table fully specifies the site of the autograft harvest. This tells us a code for the harvest would not add any information, as the source of the graft is in the 7^th character qualifier, and therefore the additional code is not necessary.

Edits in the Guidelines

While there is no change in guideline A9 that instructs that within a PCS table, valid codes include all combinations of choices in characters 4 through 7 in the same row of the table; the code table example includes device value Y “other device” in the 0JH code table.

• Guideline B2.1a for body systems had some editorial changes, listing the complete titles of the Anatomical Regions body systems and removing the Control example, since this root operation can now be coded in in other body systems. Also added was an example: Amputation of the foot is coded to the root operation Detachment in the body system Anatomical Regions, Lower Extremities.
• The root operation Extraction was added to B3.5 for overlapping body layers, stating that for root operations such as Excision, Extraction, Repair or Inspection performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded.
• In guideline B4.1b for body part that addresses the prefix “peri,” guidance is given for the periosteum: A procedure site documented as involving the periosteum is coded to the corresponding bone body part.

A New Section of Guidelines, and Updates to New Technology

A completely new section with two guidelines, section D, is for Radiation Therapy.  The new guidelines concern Brachytherapy. They instruct when separate codes are necessary from the Medical and Surgical section for Insertion. The brachytherapy source that remains in the body at the end of the procedure.  Also covered is the placement of a temporary applicator for brachytherapy delivery.  Review these guidelines carefully.

• With the addition of the Radiation Therapy section, the New Technology guidelines from section X moves to E. With some edits and the addition of a new guideline.  The updated guidelines specify when a New Technology code may be the only code. And when they may be additional codes along with codes from other sections of PCS Guidelines 2020.  One example given is for the use of dual filter cerebral embolic filtration. Code it as X2A5312 used in conjunction with a transcatheter aortic valve replacement (TAVR). Assign both codes.

While the updates to the PCS Guidelines 2020 are not extensive, there are important changes that warrant careful review. You can find the full ICD-10-PCS guidelines 2020 PDF here.

Stay Current on All Coding Updates

Stay current with all the ICD-10-CM/PCS coding updates by signing up for our YES Education webinars. Our Subscription Bundles offer 12-month access to practical, focused coding updates education for one annual fee. For information regarding the ICD-10-PCS FY 2022 coding updates and the FY 2022 IPPS Final Rule, review our article, “CMS Releases FY 2022 ICD-10-PCS Code Updates Files.” Our course on the 2022 ICD-10-PCS Updates is now available on the YES HIM Education site.