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 covered in detail the 2020 Proposed Rule for the Inpatient Prospective Payment System (IPPS) CMS-1716-P, which was published 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, updates to an existing section, new guidance on a body part, 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.
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 exceptions that were included in the updated guidelines involve a mastectomy followed by immediate reconstruction. It was a matter or timing that determined whether the mastectomy was coded. If a patient had a mastectomy during the current encounter and a subsequent reconstruction at a different episode, then the mastectomy was coded for the first encounter, and the reconstruction for the next one. This was different in the case of a mastectomy followed by immediate reconstruction during the same encounter. Before 2020, following the guidelines meant that in the case of immediate replacement, the mastectomy would not be coded 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.
- Guideline B3.1b has been updated to state 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 is to remove cancerous or potentially cancerous breast tissue, and that the reconstruction is an additional objective.”
- 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. Excision of a saphenous vein for a coronary bypass is highlighted 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 updated guideline and example are telling us that including a code for the harvest would not add any information as the source of the graft is listed in the 7th character qualifier, and therefore the additional code is not required.
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 contained in the same row of the table; the code table used as an example has been updated to include device value Y “other device” that has been added to 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 added for Radiation Therapy. The new guidelines concern Brachytherapy and instruct when separate codes are needed from the Medical and Surgical section for Insertion of 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 have been moved 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 reported and when they may be additional codes reported along with codes from other sections of ICD-10-PCS. One example given is for the use of dual filter cerebral embolic filtration, coded as X2A5312 used in conjunction with a transcatheter aortic valve replacement (TAVR); both codes are assigned.
While the updates to the 2020 guidelines are not extensive, there are important changes that warrant careful review. You can find the full document here: https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2020-ICD-10-PCS-Guidelines.pdf