ICD-10 coding challenge: The root operation Control

July 28, 2016 / By Sue Belley, RHIA

CHALLENGE QUESTION

A 72-year-old male presented to the Same Day Surgery unit of a local hospital for an aortogram with bilateral lower extremity run-off to investigate the feasibility of an arterial repair of the left lower leg due to severe arteriosclerosis of the leg that has progressed to ulceration and gangrene of the left great toe.

After completion of the arteriogram, the patient developed an expanding hematoma in the left groin at the arteriogram puncture site. The hematoma expansion could not be controlled by manual compression and therefore, the patient was taken to the Operating Room and placed under general anesthesia for exploratory surgery. The left femoral area was opened via incision, the hematoma was evacuated and the area was explored. The surgeon noted that the tip of a triangulated piece of calcified plaque was extruding from the femoral artery puncture site which prohibited the puncture site from closing after the conclusion of the earlier arteriogram. The puncture site on the femoral artery was repaired with one suture. The incision was then closed. The patient was sent to the Recovery Room and then admitted as an inpatient to a surgical floor. He was discharged two days later.

Assign diagnosis and procedure codes (excluding Radiology procedures) for this inpatient encounter and sequence appropriately.

The patient’s final diagnoses were:

• Severe arteriosclerosis of left lower leg with ulceration and gangrene of left great toe
• Postop hematoma of left groin

ANSWERS

I70.262             Atherosclerosis of native arteries of extremities with gangrene, left leg

L97.529            Non-pressure chronic ulcer of other part of left foot with unspecified severity

I97.618             Postprocedural hemorrhage and hematoma of a circulatory system organ or structure following other circulatory system procedure

0Y380ZZ          Control bleeding in left femoral region, open approach

BLOG RESPONSE

This month’s scenario gives us the opportunity to use some of the new diagnosis and procedure codes available to us in ICD-10-CM and PCS.

This patient developed a femoral artery hematoma following an interventional radiology procedure of his aorta.  There was some confusion around the assignment of the code for this diagnosis. Some of you assigned the code for a postprocedural hemorrhage of the skin/subcutaneous tissue or of a musculoskeletal structure. In this scenario, the hematoma developed at the aortogram puncture site on the femoral artery making this a hematoma of a circulatory system organ (an artery) after a circulatory system procedure (aortogram). Some of you assigned a code for an intraoperative hemorrhage/hematoma when in reality the hematoma developed after the aortogram was completed. Many of the procedural complication codes in ICD-10-CM are more specific regarding when the complication occurred (intraoperative v. postoperative), on the type of organ or structure (circulatory v. musculoskeletal, for example) and during what type of procedure (circulatory/non-circulatory, etc.), so close attention is required to select the correct code.

Close attention is also required to code ulcers, pressure and non-pressure, in ICD-10-CM. Laterality and specific location, in addition to the severity of the ulcer, are incorporated at the code level. In this example, we are able to capture some of the detail such as laterality (left) and location (toe); however, the physician did not specify the severity of the ulcer in the medical record. ICD-10-CM Official Guidelines for Coding and Reporting allow us to use medical record documentation of the severity of the ulcer that may be documented by other clinicians who are not the patient’s provider such as a nurse, wound care specialist, etc.

The root operation for this procedure may have given you pause. The first clue in this scenario is that the patient was experiencing postprocedural bleeding that the surgeon was attempting to stop. When you are faced with the situation the first thing you want to consider is whether the procedure performed meets the definition of the root operation Control. If the procedure performed does not meet the definition of any of the following root operations – Bypass, Detachment, Excision, Extraction, Reposition, Replacement or Resection – then the root operation Control is most likely the root operation of choice.  In this case, the root operation would be Control since the procedure performed – placement of  simple suture to close the femoral artery puncture site and stop by bleeding – does not meet the definitions of any of the aforementioned root operations. I noted that some of you assigned the root operation of Repair to this scenario. Repair would have been the correct root operation for this procedure had the situation not been one of postprocedural bleeding.

In case you don’t already know, the definition of the root operation Control will be revised and expanded with Fiscal Year FY 2017 updates effective 10/1/16. You can read more about this update in a recent blog post by my fellow blogger Rhonda Butler.

Sue Belley is a project manager with the consulting services business of 3M Health Information Systems.

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