Inpatient Facility Coding & Compliance Alert

Heads up: Coders will need to know even if the physician doesn’t use a device.

If your coders tackle a case today with documentation of "right carotid endarterectomy," the ICD-9 diagnosis choices are simple. All that will change, however, under ICD-10-PCS.

Best bet: Don’t scramble to educate physicians in 2014. Educate coders and start training providers to improve their documentation now.

 Say Good-Bye to the Simplicity of ICD-9  

Coders currently assign diagnosis 38.12 (Endarterectomy of other vessels of head and neck) for cases with notes such as "right carotid endarterectomy for a critical right internal carotid artery stenosis."

When you map 38.12 to its ICD-10-PCS equivalents, however, you see that providers must give more specific documentation before the case can be coded. The necessary details fall into four areas:

Type of procedure: You need to know whether the right carotid endarterectomy was a "dilation" or "extirpation." A "dilation" means that the procedure expanded an orifice or lumen of a tubular body part. On the other hand, an "extirpation" means that the procedure took or cut out solid matter from a body part.

Anatomic location/body part: Through the "critical right internal carotid artery stenosis" notation, you know that this procedure took place on the right internal carotid artery. That is one area of documentation you don’t need to update.

Approach: What approach did the physician use? Was this open, percutaneous, or percutaneous endoscopic?

Device: Similarly, you need to know what sort of device the physician used--or if she didn’t use a device at all. Your options are:

• Intraluminal Device, Drug-eluting
• Intraluminal Device
• No Device.

Beginning to take these extra steps in documentation now will mean fewer headaches in the future.

Check Out Your ICD-10-PCS Possibilities 

According to these limits of available documentation in the patient’s medical record, you have the following "Extirpation" or "Dilation" ICD-10-PSC options: