Author: Linda Kobayashi, BA, RHIT, CCS
Editor: Andrea Wong, BS, RHIT
For the past three weeks, we have addressed orthopedics. Its impossible to cover everything and that has never been our intention. We are giving you a broad overview of various body systems. For the next month we will be addressing the cardiovascular system.
Problem for this week:
The patient was admitted to the hospital directly from the ER. He complained of shortness of breath, excessive tiredness and leg swelling. According to his physician, these symptoms, which came on suddenly, may indicate heart failure. He has a history of coronary artery disease, hypertension, and ten years ago he sustained an acute myocardial infarction. Please note that the physician did not make a correlation between the HF and the hypertension. Based on his symptoms and his history, his physician ordered percutaneous placement of a Swan-Ganz catheter in the superior vena cava.
I50.9 = Heart failure, unspecified
I10 = Essential (primary) hypertension
I25.10 = Atherosclerotic heart disease of native coronary artery without angina pectoris
I25.2 = Old myocardial infarction
02HV32Z = Insertion of monitoring device into superior vena cava, percutaneous approach
Breakdown of I50.9:
- I50 = Heart failure
- I50.9 = Heart failure, unspecified
To locate I50.9: Disease Index > Failure, failed > heart (acute) (senile) (sudden).
To locate I10: Disease Index > Hypertension, hypertensive (accelerated) (benign), (idiopathic) (malignant).
To locate I25.10: Disease Index > Disease, diseased > coronary (artery) > see Disease, heart, ischemic, atherosclerotic (of).
To locate I25.2: Disease Index > Infarct, infarction > myocardium, myocardial > healed or old.
Comments for Diagnosis Codes:
- Heart failure, I50.9: There are no changes in coding guidelines between ICD-9 and ICD-10-PCS for heart failure/congestive heart failure. These terms are often used interchangeably. The physician did not state “congestive,” but regardless of whether you code “congestive heart failure” rather than “heart failure,” the codes are the same – I50.9. Heart failure(HF) occurs when the heart is unable to pump sufficiently to maintain blood flow to meet the body’s needs.
- Essential (primary) hypertension, I10: Essential hypertension(also calledprimary hypertension or idiopathic hypertension) is the form of hypertension that by definition has no identifiable cause. It is the most common type of hypertension, affecting 95% of hypertensive patients,
- Code differences between ICD-9 and ICD-10:
- Coronary artery disease: The only change in coding guidelines between ICD-9 and ICD-10 is whether or not the patient also has angina, in which case a combination code is assigned in ICD-10; unlike ICD-9 in which two codes are required. However, in our scenario, the patient does not have angina. Nevertheless, we want you to be familiar with the changes in coding guidelines. Coronary heart disease (CAD) is a disease in which plaque builds up inside the coronary arteries. These arteries supply oxygen-rich blood to your heart muscle. When plaque builds up in the arteries, the condition is called atherosclerosis.The buildup of plaque occurs over many years.
- Old AMI, I25.2: There is no difference in coding guidelines between ICD-9 and ICD-10 for old AMIs. This code refers to a healed AMI, which is a past myocardial infarction currently presenting no symptoms.
Procedure Coding: Swan–Ganz Catheterization
To locate 02HV32Z: PCS Index > Insertion of device in > Vein > Vena cava > Superior > 02HV > locate table 02H and go across the row to finish building the code as well as verify that the 4th character value of V is correct:
Insertion of Monitoring Device into Superior Vena Cava, Percutaneous Approach
Comments for 02HV32Z
- Insertion of device in: Putting in a non-biological device that monitors, assists, performs or prevents a physiological function, but does NOT physically take the place of a body part.
- Superior Vena Cava: A large vein carrying deoxygenated blood into the heart. There are two in humans, the inferior vena cava(carrying blood from the lower body) and the superior vena cava (carrying blood from the head, arms, and upper body.) It is located in the anterior right superior mediastinum.
- Swan–Ganz catheter is a special type of catheter placed into the pulmonary artery for measuring pressures in the heart, and pulmonary output.
- Guideline A4: The meaning of a body part value in the Med/Surg section is always dependent on the body system value. In our scenario, the body part value V, is the superior vena, one of the great vessels, and the Heart and Great Vessels, Body System, specifies in our scenario that the character value we should be looking for is insertion.
- Device: The value for the device is “2- monitoring device” because the main purpose of the Swan Ganz catheter, as previously mentioned, is to measure the Pulmonary Arterial (PA) pressure and output when the heart is both in diastole and systole. The catheter can also monitor blood temperature, cardiac output, as well as sample blood specimens such as oxygen (O2) saturation.
- Approach: The procedure is considered an invasive procedure because the device is inserted into the body via percutaneous approach as indicated in our case study. The catheter is inserted through a sheath percutaneous into any of the central veins such as the internal jugular, subclavian, antecubital, or femoral vein. The catheter is then advanced through the venous system (SVC) into the entry of the right side of the heart. A balloon is then inflated in the right atrium, advanced past the tricuspid valve (aka AV valve), into the right ventricle, and then through the pulmonic valve, and finally to the Pulmonary Artery (PA).
- Patients who require invasive pressure monitoring are critically-ill patients that require constant attention by the healthcare team.
DIRECTIONS FOR LOCATING PROCEDURE CODE(S) BY DIRECTLY GOING TO THE TABLES
INSERTION OF SWAN-GANZ CATHETER
- Step 1, Section: Determine the correct section in your PCS coding book. Since you know or should know that the superior vena cava is one of the great vessels, this takes you to the Heart and Great Vessels Body System section. The first character value in this section is always 0.
- Step 2, Body System: Determine the body system. You now know that the correct Body System is the Heart and Great Vessels, based on the statements made in Step 1. So far we have 02.
- Step 3, Root Operation: Determine the root operation. Root operations are listed alphabetically. You are already in the Heart and Great Vessels Body System. Now you need to locate the root operation, Insertion, for a total of 3 character values, 02H.
- Step 4, Body Part: Determine the body part. Now you need to find the superior vena cava. You know from the comments made under this procedure what the function of the superior vena cava is. We now have enough characters to go directly to the correct table. The character values are 02H. Simply locate table 02H and look for the 4th character, the superior vena cava (V.) We are up to 4 character values, 02HV.
- Step 5, Approach: Determine the Approach. This is very simple because the problem specified that the approach is percutaneous. So far we have 02HV3; 3 is the character value for Percutaneous.
- Step 6, Device: Determine the Monitoring Device. If there is a device left in place at the end of the procedure, it must be coded. In our scenario, the character value 2 captures Monitoring Device; we now have 02HV32.
- Step 7, Qualifier: Determine the Qualifier. Qualifiers provide further details about the procedure. In our scenario the character value of Z indicates that there is no new information to be added. Also, Z is a placeholder – Z is to ICD-10-PCS what X is to ICD-10-CM.