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Robert Gold, MDThe ICD-10-PCS code set scheduled to be implemented in the United States in October 2014 is missing features necessary to denote certain operative procedures performed on children with congenital heart defects or anomalies, according to a letter prepared by DCBA, Inc.’s founder and CEO Dr. Robert Gold.

The letter was prepared at the request Children’s Hospital of Philadelphia with the support of Boston Children’s, the cardiovascular services of many other children’s hospitals and the Children’s Hospital Association to be sent to Patricia Brooks of the Centers for Medicare & Medicaid Services.

Many procedures for congenital heart diseases currently are coded in ICD-9 using the preface “repair of,” followed by the name of one of several abnormalities or conditions, Gold explained. Yet the pending ICD-10-PCS coding set has what he labeled “significant deficiencies” that, if left unchecked, will present serious issues as soon as October of next year.

“This is a significant finding regarding accurate procedure data collection for this pediatric population,” Kim Charland, senior vice president for Panacea Healthcare wrote in a statement to ICD10monitor. “We hope that the partial ICD-10 code freeze that is in effect does not stop CMS from addressing this.”

A preliminary list of procedures listed in the letter included an arterial switch, an atrial switch, use of a modified Blalock-Taussig shunt, a truncal valve, and a Dacron patch closure of a ventricular septal defect (VSD), among others.

“We strongly suggest that a group be commissioned including one or two pediatric inpatient coding professionals, a pediatric cardiologist and a pediatric cardiothoracic surgeon to meet with Ms. Brooks and her appropriate staff to discuss, describe, and draw (if needed) the operative procedures as a first step” toward modifying existing code sets, developing new code sets or dropping back and creating simple codes for the procedures at issue, Gold wrote in his letter.

Gold’s letter included the following descriptions which were presented by the coding professionals at CHOP.

Arterial Switch:

No code for the transplantation of the coronary arteries from the native aorta to the native PA. This part of the procedure involves cutting out the coronary arteries (called buttons) from the aorta, patching the holes in the aorta and implanting the coronary arteries on the pulmonary artery. The surgeon is repositioning them.

Reposition of the CORONARY ARTERIES is NOT AN OPTION in ICD 10 PCS. Only reposition of an UPPER Artery is available and the coronary arteries are part of the Heart and Great Vessel body system (Character 2).

Modified Blalock-Taussig shunt:

There is NO code available for Bypassing the Innominate artery to the pulmonary artery. The innominate is an Upper arteries (character 3) and the Pulmonary artery is part of the Heart and Great Vessel body part. This was sent to nosology and was “escalated”

Placement of conduit from left ventricle to the aorta for LVOTO repair:

The root operation would be Bypass but there is no code to indicate Bypass from the left ventricle to the aorta WITH A DEVICE (procedure is always done with one of the following devices: synthetic, autologous venous tissue graft, intraluminal device drug eluting or a non-autologous tissue substitute.)

Rastelli Type A for Complete AV canal defect (a severe defect in which there is a large hole in the center of heart where the upper chambers (the atria) and the lower chamber (the ventricles) meet.

The purpose of this operation, and final result, is the creation of a mitral valve between the left atrium and the left ventricle and a tricuspid valve between the right atrium and the right ventricle. There is no code in ICD 10 PCS to cover this as a root operation since you cannot use create and there are now 2 valves where there was just one. There is the use of supplemental material but the final outcome of the procedure is a CREATION of 2 new valves in the heart.

Senning repair (Atrial Switch):

An atrial baffle is fashioned in situ by using the right atrial wall and atrial septum to re-direct the venous blood to the left ventricle. No device is used but the only way to code root operation Supplement atrial septum (which is correct anatomically) is to choose a device and NO DEVICE IS USED. A flap is made from the patient’s own tissue. Additionally, root operation Transfer is not even an option under Heart and Great Vessels.

Truncal Valve:

Not even in ICD-10 PCS as a body part. The truncus arteriosus is the outflow tract from the embryonic heart that is supposed to divide into an aorta and a pulmonary artery. When this does not happen, a single outflow tract remains. As no adult has such an anomaly, it is understandable that there have been no codes developed for its surgical interventions.

Dacron patch closure of Ventricular Septal Defect:

Occlusion of the VSD is the primary goal of this procedure but this root operation does not give the choice of the Ventricular Septum. Supplement allows the vent septum as a body part with the synthetic patch but is not truly the correct root operation. Replacement also allows the ventricular septum as a body part with the synthetic patch but once again is not truly the correct root operation considering the primary goal of the procedure.

Patch closure of Atrial septal defect or PFO: (Same problem as above.)

“This is not an issue that can wait until October 2015,” Gold added. “It is clearly a deficiency that was not planned for, and it must be addressed as quickly as possible so that all of our cardiothoracic surgeons can have an opportunity to review and comment on the ICD-10-PCS codes pertinent to congenital heart cases.”

Donna Pickett, medical classification administrator for the National Center for Health Statistics, and Nelly Leon Chisen, director of coding and classification for the American Hospital Association, are copied on Gold’s letter per official recommendations.

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Mark Spivey is a national correspondent for the ICD10monitor.

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