Annual ICD-10-PCS FY 2021 update summary

June 22, 2020 / By Rhonda Butler

The ICD-10-PCS update for FY 2021 was posted on May 28. Thankfully, there has been nothing unusual about the update cycle for ICD-10-PCS. There have been no interim updates and all the changes included in the files go into effect on October 1. The complete, downloadable content files are available here. Given the limitations of a blog, I will only cover the changes I find interesting and comment as the mood strikes me.

ICD-10-PCS code tables

This year there are 544 new codes. No codes were deleted nor were code titles revised this time around. The list of new codes is available in the text file “codes_addenda_2021” located in the zip file “icd10pcs_codes_2021_0”. (In fact, you may find it useful to open it now and scan along with this blog!) You can easily scroll through the list to get a general idea what’s been added to the tables. If you haven’t done this before, you will see very quickly that individual codes and code titles repeat in patterns, so are much more efficiently represented in the PCS tables. And while 544 sounds like a lot, the new codes can be lumped into broad categories of change. Where the number of codes is significant, I include the number in this summary, so you can see where the bulk of the new codes come from. Quantity is not an indicator of significance, it just shows when a new data element has been applied broadly.

Existing PCS tables expanded to capture new sites, techniques, or implanted devices

• Till now, the typical use of the Fragmentation tables has been for lithotripsy of the urinary system—zapping kidney, ureter, or bladder stones into powder so they can pass out of the body instead of causing excruciating obstetric-labor-type pain. Now these types of techniques can be used for zapping two different things that can clog the vascular system. Intravascular lithotripsy is used alone or with stent placement to treat plaque in the arteries. And Ultrasound-assisted thrombolysis is used to help break up a blood clot that is parked in a vessel and blocking traffic. Fragmentation tables added to the vascular system are tables 02F, 03F, 04F, 05F (116 codes).
• A code was added to capture a new percutaneous left-to-right atrial shunt, inserted as a treatment for congestive heart failure. This procedure is coded in Bypass table 021.
• A new device value was added to the root operation Fusion tables 0RG and 0SG, (78 codes) to allow data capture for joint fusion procedures that use a sustained compression internal fixation device. The claim is that this device produces a more stable joint fusion because it contains a nickel/titanium alloy called Nitinol added to it, so it can stretch and recover—think metal that does yoga.

Existing tables expanded for completeness

• One of the most common isotopes used in brachytherapy, Cesium 131, was added to several Brachytherapy tables in section D, Radiation Therapy (64 codes). Maybe this procedure is rarely done as an inpatient procedure, so no one noticed it was missing? Anyway, it’s there now, so we can let the mystery be.
• In conjunction with the brachytherapy request, the device value Radioactive Element was added to the root operation Insertion tables for several body systems (157 codes). This supports a coding convention to assign a separate code for brachytherapy procedures when a radioactive source is left in the body (e.g., radioactive seeds placed in prostate tissue).
• Procedures to remove ectopic pregnancy are commonly done laparoscopically, and the percutaneous endoscopic was missing from Extraction table 10D in the Obstetrics section. The open approach also got added for the rare cases when laparotomy is necessary.
• Another table beefed up for completeness is table 4A0, where qualifiers were added to capture portal venous pressure and musculoskeletal compartment measurements.

New technology procedures

Many of the proposals to add codes for new technologies are created to support a CMS payment initiative called NTAP (New Technology Add-on Payment). Many of these proposals are for techniques or equipment not typically coded during a hospital stay. (The coding community pretty much hates that ICD-10-PCS is being used this way, but they also are aware that the people who make healthcare policy are not the people who implement it.)

Because providers can receive additional reimbursement for using these technologies at their facility, it’s important to know the codes are there. It’s also important to know that not all section X codes are eligible for NTAP, and not all procedures eligible for NTAP payment are found in section X. However, the ICD-10-PCS Index is updated with terms that are likely to be used in the documentation, so the new codes are pretty easy for coders to find.

Some examples from this year are:

• A mineral-based spray used endoscopically to treat gastrointestinal bleeding. The spray-on bentonite powder avoids having to come in contact with the bleeding tissue (which can cause more bleeding).
• Software that “reads” a CT angiogram of head and neck vessels and provides an early provider alert, for scans showing a large vessel obstruction that could be treated with mechanical thrombectomy. This is coded in section 4, as “measurement of intracranial arterial flow.”
• A couple of tests on blood and lower respiratory secretions claim faster, more precise measurement of the responsible organism, for focused antibiotic treatment of sepsis and pneumonia respectively.
• A new sub-type in section B Imaging has been created to classify other modes of imaging. Generously named “Other Imaging,” it allows for the “not elsewhere classified” procedures to be captured without creating a bunch of sub-types, then uses qualifiers in the table to specify the new imagining sub-type. This year, the new tables were populated with two types of procedures, both involving stuff that glows. One uses indocyanine green dye (ICG) for intraoperative imaging of the biliary system during cholecystectomy. The other one uses bacteria’s tendency to fluoresce, with a special filter and a hand-held device for management of open wounds such as chronic skin ulcers. Imagine putting this technology to use “diagnosing” the all-you-can-eat buffet! (Digression: will such things exist in a post-COVID-19 world?)

Next are a couple examples of section X codes for surgical procedures that are typically coded on an inpatient record.

• Table XNU was created to capture a new system for restoring height in osteoporotic vertebral fractures. The implant, called SpineJack, looks like a teeny car jack—and is cranked up like one! They are typically inserted in pairs, one on each side of a vertebra.
• Codes were added to table X2A for a specialized extracorporeal bypass performed during carotid artery stenting procedures (TCAR). The techniques uses a negative pressure gradient to siphon the blood out of the neck, filtering it for bits of plaque dislodged during the procedure before returning it to the body via the femoral vein. The idea is to lower the risk of embolic stroke that can be caused by tiny bits of gunk dislodged during the stenting procedure. This technique is new-ish, having received FDA approval in 2015, and is not participating in NTAP. However, it is classified section X, along with similar filtering techniques that did apply for NTAP. Like I said earlier, not all section X codes are NTAP and vice versa, not all NTAP-eligible procedures are coded using section X codes. All part of the fun of coding!

New technology drugs

The majority of the NTAP applications are for new drug treatments, often for cancer or infection. These are cross-listed in the Index and Substance Key by generic name and brand name, so they are easy to find. The only specific one I will mention is the new table XW2 Transfusion. CMS finalized a different option from that proposed at the C&M meeting, and they have been getting questions from coders. With permission from CMS, I can tell you that the decision was intentional, to use root operation Transfusion and create new table XW2 for two new CAR T-cell therapy drugs, rather than use XW0 where previous CAR T-cell New Tech drugs were classified. The final decision was based on public comment and on the PCS root operation definitions—CAR T-cell therapy is considered a blood product, so it is more accurately classified to the root operation Transfusion. Stay tuned, because CMS plans to propose additional changes so that all CAR T-cell therapies are classified to the new Transfusion table XW2.  In the meantime, follow the coding instruction in the Substance Key and cross-listed in the Index.

Official ICD-10-PCS guidelines

If you have made it this far, a virtual gold star for you! I’ll finish by summarizing the guideline changes. There are only two new guidelines and two minor changes to existing guidelines:

New guideline B3.18 gives the principle (and gives examples) clarifying coding instruction for surgical scenarios when excision or resection of a body part and replacement/reconstruction at the site are performed during a single operative episode. Guideline 3.1b was revised in conjunction with the new guideline, to remove an “Exception” that is used as an example in the new guideline.

New guideline B5.2b establishes a convention for coding percutaneous endoscopic (e.g., laparoscopic, arthroscopic) procedures when a small incision is extended to facilitate removal of tissue or other completion of the procedure such as anastomosis. These types of procedures should be coded using the approach value Percutaneous Endoscopic rather than the approach value Open.

B3.10c was revised to clarify the meaning of a parenthetical phrase in the guideline. No biggie, it just makes it clearer that bone graft or bone substitute is expected to be used in the interbody fusion device.

Rhonda Butler is a clinical research manager with 3M Health Information Systems.

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