From 3M Health Information Systems
What happens in ICD-10-PCS stays in ICD-10-PCS: Understanding the device value, part 2 of 3
In the first part of this blogatribe, we got the basic principle of the device value under our collective belt. The principle, recapped: the sixth axis is a way of capturing additional useful information about a procedure, and that when the device value is something other than Z No Device in root operations it is because it would be useful—rather than a redundant bother—to specify that an appliance (a pacemaker, or a very small microwave oven so you can have popcorn with your in-flight movie) or other material central to the objective of the root operation (graft stuff, prosthesis stuff) was left in the body at the end of the procedure, doing its thing.
Click here for part one if you want to review before continuing on.
Pretty straightforward, if you don’t get all deep and philosophical about devices, and if you remember where you are— just another Matrix, a model of reality that doesn’t pretend to tell marketers or people at the FDA the deep meaning of the word device. So where’s the problem? It turns out that people are getting stuck on the root operation Revision, and in order to, quote, help them get, quote, unstuck they get creative with informal rules about how to use root op Revision. There are two creative rules out there circling in the infosphere, which I will call Mississippi Mud and Spumoni (because it is a mysterious Italian-inspired ice cream flavor from my childhood, when Neopolitan was the height of decadence, and because it is a great word).
Clarifying Mississippi mud
The Mississippi Mud rule is an informal rule circulating in the PCS infosphere that emerged from deep philosophical considerations of ideological purity inside PCS, rather than the effective use of the PCS tables to capture information as coded data for financial transactions and for analysis of quality, cost or outcomes. This informal rule goes something like this: once a procedure has been coded saying that a device was left at the site at the end of the procedure, any subsequent procedure on that device, other than removing or replacing it altogether, is always coded as a Revision of that device. No exceptions.
The root operation definition of Revision is perfectly well known to most of you—you probably mumble it in your sleep—but for that tiny minority who cannot say it three times fast, it is inserted here.
Revision: Correcting, to the extent possible, a portion of a malfunctioning device or the position of a displaced device
Explanation: Revision can include correcting a malfunctioning or displaced device by taking out or putting in components of the device such as a screw or pin
Includes/Examples: Adjustment of position of pacemaker lead, re-cementing of hip prosthesis
In many cases, the Mississippi Mud rule is consistent with good coding practice in PCS. In other words, with or without a rule, Revision would be the best root operation to code in such cases. So, why do we need the extra informal rule on top of the fundamental principle of choosing the best root operation for the procedure? Jinx—that was my point! Additional informal rules that use words like “always” should cause your eyebrows to go up, and large cartoon question marks to hover around your head.
A rule that says something is always the case also invites us to hunt for exceptions. Here is an exception to the Mississippi Mud rule, where coding a subsequent procedure to root op Revision is clearly a not so good idea:
A patient has had a CABG using saphenous vein graft. Goes home, does everything right, takes up golf again. CAD progresses and three years later he has a heart attack, so he gets an emergency repeat CABG where an additional vein graft is attached to the old saphenous vein graft, upstream of the new blockage.
Pretend you are at the optometrist. Which one is clearer, 1?
0210093 Bypass Coronary Artery, One Site from Coronary Artery with Autologous Venous Tissue, Open Approach
02WA07Z Revision of Autologous Tissue Substitute in Heart, Open Approach
Bypass, right? Here are a couple of reasons.
Clinical: This is progression of disease, the “device” did not “malfunction.” It is not the poor vein graft’s fault that the guy has a talent for lining his coronaries with plaque.
Practical: The Revision code is garbage as data. This code gives us next to no idea what was done to the patient, and so it will not aggregate up to be grouped among the CABG procedures for all those reports that look at case mix, quality, cost and so on.
Here’s some homework. Code these examples yourself, with two options—the good option and the Revision option—and come up with your own reasons why the good option is good and the Revision option is not so good.
Example 1: A female patient has bladder cancer. The bladder is entirely resected, and she has an ileal pouch procedure done to replace the resected bladder. Six months later at a follow-up cystoscopy a polyp in the ileal pouch is excised.
Example 2: A patient was in a serious motorcycle accident and required sizeable skin grafts to repair the injury to his upper arm and forearm including the elbow. He underwent a subsequent procedure where Z-plasty incision was performed for a scar contracture restricting movement at the elbow.
In part 3, we’ll do the Spumoni rule in part 3, and then we’ll be done, I promise.
Rhonda Butler is a clinical research manager with 3M Health Information Systems.