ICD-10-PCS: Root Operation of Creation Creates More Problems

by Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA

The root operation of Creation has been problematic since the change in the definition for FY2017. Questions abound and coders are confused about this complex procedure. At the September 12, 2017 Coordination and Maintenance Committee, a proposal was made by CMS to make another change to the 024 table for Creation in Heart and Great Vessels by adding Z, No Device to this table.

This proposal has serious issues, along with the FY2017 change to the definition. The original definition of Creation was “Making a new genital structure that does not physically take the place of a body part.” For FY2017, it became “Putting in or on biological or synthetic material to form a new body part that to the extent possible replicates the anatomic structure or function of an absent body part.” The 2017 change should never have been made because the definition overlaps with the definitions of both Replacement and Supplement, causing a conflict with the ICD-10-PCS design requirement of mutually-exclusive root operations with no overlap. The “completeness” criteria said that “There should be a unique code for all substantially different procedures” and this criteria is no longer met due to this change. I ask that you read the proposal and send comments to CMS by November 13th. They need to hear from you.

Here’s some history on this problem: The pediatric coders wanted a way to identify the work that is done in both “Truncus Arteriosus” and “Common AV Valve” (or the alternate name of “Atrioventricular septal defect”) procedures. Specific qualifiers were suggested and those qualifiers were added in FY2017, allowing us to correctly identify these procedures. Changing the definition of the root operation of Creation was completely unnecessary but was approved at the same time. This newest proposal makes the problem more complex by causing further overlap with the root operation of Repair.

Clinically, in the Common AV valve anomaly, the patient is missing much of their atrial septum and much of their ventricular septum. This allowed the tricuspid and mitral valve to form as one valve across the middle of the heart during development. When the atrial and ventricular septums are supplemented with tissue or synthetic, the common value is, in essence, divided into two. This is not creation. This is supplement of the septums, just as it is with any other septal defect procedure. Then, additional suturing may be required of the mitral valve and the tricuspid valve, such as suturing multiple leaflets into one. Again, this is not a creation. This is repair of the mitral valve with the qualifier of AV valve, left or the tricuspid valve with the qualifier of AV valve, right. With these qualifiers, the procedures are correctly coded and fully identified as unique procedures. No device is added and no valve is created.

In the Truncus Arteriosus procedure, the pulmonary trunk is sewn directly to the aorta to repair the aorta. The single valve that is present is used as the aortic valve. No device is added to the valve. Often a leaflet is excised. If the valve has “floppy leaflets,” the valve may have a sutured annuloplasty, such as a De Vega annuloplasty, to tighten the annulus. Again, no device is used. The repair of the truncal valve is assigned the qualifier of truncal valve, uniquely identifying the procedure. In both these conditions, the procedures on the valves do not use devices, and therefore, the current table is unusable. This newest proposal to add Z, No Device does not fix the problem, but rather makes the situation worse. It’s time to undo the problem, not compound it.

Therefore, I strongly recommend that the root operation definition of Creation be returned to the original wording to avoid the situation of two possible ways to code Supplement and Replacement procedures on these structures. Returning the root operation to its original definition would be the easiest way to solve this issue, along with the necessary deletion of the 024 table.

If you care about the accuracy of the code set as I do, please send your comments to CMS to request the return of the definition of Creation to the original definition and eliminate all of these problems. Comments are due by November 13th, but do it now. Feel free to use my explanation in your comments, if you’d like to. Send an email to Pat Brooks, RHIA at [email protected] to register your lack of support for this current proposal and ask for the return of the original Creation definition.

An accurate code set is vital to providing quality health care data in this country. Tell CMS to fix this problem! To read the complete proposal, go to https://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/Downloads/2017-09-12-Agenda.pdf, page 13.

Looking for a comprehensive and insightful review of the October 1, 2017 Code Updates? Consider Lynn’s online courses: ICD-10-CM Code Update and ICD-10-PCS Code Update available from Libman Education. Learn more here.

About the Author

Lynn Kuehn is president of Kuehn Consulting, LLC, in Waukesha, Wisconsin, a consulting firm specializing in ICD-10-PCS coding for the inpatient setting. Lynn is a nationally recognized trainer on ICD-10-PCS and other HIM-related topics. Lynn served on the AHIMA Board of Directors and authored several of AHIMA’s most popular books including ICD-10-PCS: An Applied Approach and Procedural Coding and Reimbursement for Physician Services. Together with her co-Author Theresa Jorwic, Lynn received the Triumph Literary Legacy Award from AHIMA for ICD-10-PCS: An Applied Approach. Called the “go-to” resource for learning and mastering ICD-10-PCS, ICD-10-PCS: An Applied Approach provides step-by-step instructions and exercises at all levels, and is used throughout Kuehn’s ICD-10-PCS courses authored for Libman Education.

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