ACDIS November 2018 Cooper Hospital

ACDIS November 2018Cooper Hospital

Mike Swierczynski RT(R)(CV), MS, R.R.A.

Patricia Swierczynski BSN RN CCDS CRC

Neurointerventional

INTRACRANIAL

Anatomy

Intracranial

Common sites Circle of Willis:The Jersey Circle

Aneurysm Types

Clip Coil Stent

Coil w/ Stent

Stent protected coil

Stents

Pulserider

Before and after

Coil

Stroke Embolic /Ischemic

ThrombectomyStentriever (Solitaire & Trevo)

Stent Triever

Penumbra

TICI SCORE ( Thrombolysis in Cerebral infarct)

• Timeliness of reperfusion:• Description: Ischemic stroke patients with a large vessel cerebral occlusion (i.e., internal carotid artery (ICA) or ICA terminus (T-

lesion; T-occlusion), middle cerebral artery (MCA) M1 or M2, basilar artery) who receive mechanical endovascular reperfusion (MER) therapy within 120 minutes (>/= 0 min. and </= 150 min.) of hospital arrival and achieve TICI 2B or higher at the end of treatment

• Rationale: The Thrombolysis in Cerebral Infarction (TICI) Reperfusion Grade is used to measure cerebral reperfusion. Results with this scoring system range between zero and three: 0 (no perfusion); 1 (perfusion past the initial occlusion, but no distal branch filling); 2 (perfusion with incomplete or slow distal branch filling); and, 3 (full perfusion with filling of all distal branches). Reperfusion past the target arterial occlusion and into the distal arterial bed and terminal branches, in conjunctionwith recanalization of the target arterial occlusion, demonstrates flow restoration or revascularization.

• Endovascular therapy (EVT): is now the standard of care for treatment of acute ischemic stroke due to large-vessel occlusion (LVO). In 2015, the American Heart Association/American Stroke Association published a focused update to the 2013 Guidelines for the Early Management of Patients with Acute Ischemic Stroke regarding endovascular treatment (Powers WJ, et. al., 2015). Endovascular therapy with a stent retriever is recommended for eligible patients. To ensure benefit, reperfusion to TICI 2B/3 should be achieved as early as possible and within 6 hours of stroke onset. As with IV t-PA, reduced time from symptom onset to reperfusion with EVT is highly associated with better clinical outcomes. Recent recommendations from the Society of Vascular and Interventional Neurology (SVIN) offer procedural metrics which include time from hospital arrival to groin puncture less than 90 minutes, and time from groin puncture to TICI 2B or better or conclusion of procedure less than 60 minutes (English JD, et. al., 2016).

Pt presented with Global Aphasia and Right hemiparesis Newly Dx: Paroxysmal afib not anticoagulated

Procedure: Cerebral angiogram and mechanical thrombectomy

INTERVENTION:Utilizing a 0.038 inch Glidewire within a Sim-V catheter, the left common carotid artery was catheterized. Next, the 088 Neuron Max was guided over the Sim-V catheter into the left internal carotid artery proximally. Next, utilizing a synchro 2 microwirethe 068 penumbra Ace catheter/ Trevo microcatheter construct were navigated into the proximal middle cerebral artery. The Trevo microcatheter was then navigated into the distal M2 middle cerebral artery. Utilizing standard technique, the 4 x 30 mmTrevostentriever was then delivered across the site of thrombus for 4 minutes and then removed under constant aspiration. Post

treatment angiography demonstrated removal of thrombus.The parent and branch arteries were widely patent on final angiography, otherwise unchanged in appearance in comparison to pre-embolization imaging. At the completion of the procedure, the catheter and sheath were removed and hemostasis in the right groin obtained by placement of a 6-French Angioseal arteriotomy closure device. The device was deployed without complication.No new neurological deficits or complications were encountered during or immediately following the procedure.

03CG327: Extirpation of matter from intracranial artery using stent Retriever perc approach

Procedure Note Example

I10 Thrombectomy

•Extirpation; 03CG3ZZ Extirpation Artery intracranial percutaneous No qualifier

• Penumbra

• Stentriever (Solitaire & Trevo) 03CG327 Extirpation of upper artery intracranial percutaneous stent retriever

( CMS Oct 1 2018 Endovascular Thrombectomy of Intracranial and Extracranial Arteries: Option 2 approved: In table 03C, Extirpation of Upper Arteries, create qualifier value 7 Stent Retriever to distinguish endovascular thrombectomy of intracranial and extracranial arteries using stent retriever from other extirpation procedures.

Interim coding advice: Continue to code endovascular thrombectomy of the intracranial and extracranial arteries to table 03C, Extirpation of Upper Arteries.

Discussion Extirpation / Thrombectomy FailedQuestion:

I have a question regarding a failed attempt at a thrombectomy (Attempted mechanical thrombectomy of M1 occlusion, s/p unsuccessful mechanical thrombectomy. Procedure terminated after multiple attempts at clot. The M1 segment remained occluded with no recanalization.

• According to coding instructions we are to count those cases that were attempted but failed. My issue is this attempted/failed case did not have the thrombectomy attempt coded. I sent a note to our coders and was informed when a procedure is unsuccessful they code it to the root operation that was completed, in this case the dilation. Had no dilation been done and they only attempted the(thrombectomy extirpation they would have coded it to an inspection. Either way, they would not code the extirpation if it was not successful. That being said if we do not enter that procedure code it will not allow us to answer the questions pertaining to the thrombectomy. I did not want to enter a code for a procedure that was not coded in the medical record. Can you please advise how we should handle these cases for abstraction of the thrombectomy questions and entry in to the database. Thank you for your help on this issue.

Answer:

• There is no way in either ICD-10-CM or ICD-10-PCS to code a failed procedure. In the event of an unsuccessful thrombectomy, i.e. meaning that the extirpation procedure was not performed, it is possible for the coder to select a code associated with the root procedure accomplished.

• There is a procedure coding guideline B3.3 that states: "If a procedure is discontinued before any other root operation is performed, code the root operation for the body part or anatomical region."

AHA Coding Clinic for ICD-10-CM and ICD-10 PCS, 3Q 2015, Volume 2, Number 3, Pages 8-12

Question:

A patient with angina was seen for percutaneous coronary intervention. The procedure was aborted after several unsuccessful attempts to cross an occlusion at the right coronary artery. The coronary vessel was not dilated. How should the procedure be coded?

Answer:

Per the ICD-10-PCS Official Guidelines for Coding and Reporting for discontinued procedures B3.3, “If a procedure is discontinued before any other root operation is performed, code the root operation Inspection for the body part or anatomical region inspected.” The correct body part value is “Heart” rather than “Great Vessels,” because the coronary arteries are the arteries that supply the heart muscle. The great vessels are the large arteries and veins that attach to the atria and ventricles of the…

https://manual.jointcommission.org/Manual/Questions/UserQuestionId03Cstk100184

Occlusion v Restriction Embolization

CMS 2019 Oct 1 B3.12• If the objective of an embolization procedure is tocompletely close a vessel, the root operation Occlusion is coded

• If the objective of an embolization procedure is tonarrow the lumen of a vessel, the root operation Restriction is coded

➢Embolization of a cerebral aneurysm is coded to the root operation

Restriction, because the objective of the procedure is not to close off the

vessel entirely, but to narrow the lumen of the vessel at the site of the

aneurysm where it is abnormally wide.

➢Tumor embolization is coded to the root operation Occlusion, because the objective of the procedure is to cut off the blood supply to the vessel.

Aneurysm coil clip stent; Restriction

Restriction➢0 medical surgical➢3 Upper Arteries ( body system)➢V Restriction ( root operation)➢G Intracranial ( body part)➢3 Percutaneous ( approach)

➢D Intraluminal ( device ); 03VG3DZ ➢C Extraluminal; 03VG3CZ ➢B Intraluminal device bioactive 03VG3BZ ( glue)➢Z No device 03VG3Z➢Z All no Qual 03VG3ZZ

Open crani in OR

• External Clip aneurysm in open crani; 03VG0CZ: Restriction of intracranial artery w/ extra luminal device open approach

Clinic for Coil /Stent Embolization • AHA Coding Clinic for ICD-10-CM and ICD-10 PCS, 1Q 2016, Volume 3, Number 1, Pages 19&20

Question:

A 58-year-old female presented with right superior hypophyseal aneurysm and was taken to

interventional radiology for stent assisted coil embolization of the aneurysm. Provider

documentation states that a catheter was used to deploy a stent in the supraclinoid internal

carotid artery across the neck of the aneurysm, and then coils were introduced through the

catheter into the aneurysm. What is the correct code for the embolization? Is a separate code

Answer:

Both the stent and coils are being used at the same site for the same objective, to restrict the

lumen of the intracranial artery, and only one code is necessary. Although both body part

values, internal carotid and intracranial, describe the procedure site, intracranial artery more

accurately captures the fact that the surgery is intracranial, because the documentation states

that the procedure was done on the supraclinoid portion of the internal carotid artery. Assign

only the following ICD-10-PCS code:

03VG3DZ Restriction of intracranial artery with intraluminal device, percutaneous approach

Extracranial Facial and Neck Bleeds

• Epistaxis

• Tracheostomy

• Tumors

Embolize; Glue, Coils, Particles, Spheres

Occlusion Facial Procedures

• Occlusion Artery Face Intraluminal device no qualifier

03LR3DZ

✓ Nasopharyngeal

✓ Sphenopalentine

SAH v SDH v EXTRADURAL

Burr Holes: CDI June 2018 Ahima question to change to OPEN and brain BX.****************pending answer

Intracranial Bolt v Ventriculostomy

Ventriculostomy

EVD; External Ventricular drain;

Drain cerebral ventricle (external) perc drainage device no qualifier

009630Z

Bolt/ CAMINO ICP • See Coding Clinic, Third Quarter 2009 Page: 16

• What is the difference between code 01.26, Insertion of catheter into cranial(s) cavity or tissue, code 01.28, Placement of intracerebral catheter(s) via burr hole(s), and code 01.10, Intracranial pressure monitoring?

Answer:

• Code assignment is based on the reason for placement of these catheters. Assign code 01.10 when the catheter is inserted for monitoring of intracranial pressure. Assign code 01.28 when a burr hole is created specifically for the placement of an intracranial catheter that is used for delivery of medication directly to the brain. Code 01.26 is assigned for insertion of an intracranial catheter that is used to deliver liquid brachytherapy radioisotopes directly to malignant brain tumors within the cavity created by the surgical removal of the tumor.

• Ask yourself intent;

**********OLD:

• 4A103BD Monitoring of Intracranial Pressure, Percutaneous Approach

• 4A107BD Monitoring of Intracranial Pressure, Via Natural or Artificial Opening

June of 2018 AHA Letter from CDI:Assistance in ICP procedure coding;(According to AHA Coding Clinic for ICD-10-CM and ICD-10 PCS, 2Q 2016, Volume 3, Number 2, Pages 32&33, an arterial line placement is coded to 03HY32Z, Insertion of monitoring device into upper artery, percutaneous approach, for insertion of the arterial catheter.)Can this same logic be applied to the insertion of an ICP monitor?

AHA Response ICP monitoring:For facilities that wish to track the information pertaining to the pressure monitoring, it is appropriate to assign codes for both

the insertion of the monitor and the monitoring, if desired. Therefore, based on the documentation submitted, you may assign codes 00H032Z, Insertion of monitoring device into brain, percutaneous approach, for the insertion of the monitoring device and 4A103BD, Monitoring of intracranial pressure, percutaneous approach, to capture the monitoring. **********NEW:

00H032Z Insertion device in brain perc approach 4A103BD Monitoring of intracranial pressure , percutaneous approach ( capture monitoring)

*****The advice provided in coding clinic results formal collaboration; American Hospital association (AHA)The American health information management association ( AHIMA)Centers for

Bolt -Valid OR

AHA Coding Clinic for ICD-10-CM and ICD-10 PCS, 2Q 2016, Volume 3, Number 2,Pages 29&30

Question:The patient is a 25-year-old man who was involved in a high speed automobile accident. Hepresented to the Emergency Department and was admitted with an acute right subduralhematoma with compression of brain and significant right to left midline shift withherniation. He underwent right frontotemporal parietal decompressive craniectomy,evacuation of acute subdural hematoma, left frontal bur hole, and placement of intracranialpressure monitor. A portion of the skull was removed to allow room for the swollen brain.The bone flap was then frozen and stored in the bone bank. How is the removal and storageof the bone flap coded? What are the appropriate ICD-10-PCS procedure codes for thissurgery?

Answer:

• The objective of the decompressive craniectomy is to release pressure on the brain.Therefore, Release is the appropriate root operation. Assign the following ICD-10-PCScodes

•00N00ZZ Release brain, open approach, for the parietal decompressive craniectomy00C40ZZ Extirpation of matter from subdural space, open approach, for the evacuation ofthe hematoma4A103BD Monitoring of intracranial pressure, percutaneous approach

• insertion of bolt **********00H032Z ( now valid OR)

Associated codes w/ stroke or Aneurysm;➢Broca: motor understand but can’t produce words

( expressive aphasia) F80.1

➢Wernicke’s: can produce but don’t understand

( Wernicke’s aphasia) F80.2

➢Left stroke: right hemiplegia I69.351

➢Right stroke: left hemiplegia I69.353

➢Cortex( lobes): Dysphasia following infarct I69.321

➢Shift: Brain compression G93.5

Trauma S06.2X

➢Cerebral/ Brain Edema G93.6

Trauma S06.1X

THANK YOU!Swierczynski-michael@cooperhealth .edu [email protected]