ICD 10 Coding Alert

Hint: Even if the physician doesn't use a device, you need to know that.

If the physician documents a "right carotid endarterectomy," you can easily report your ICD-9 procedure code -- but your potential selections become a little more complicated in ICD-10-PCS.

If you want to avoid having to scramble to educate physicians in 2014, start improving your documentation now.

The Simplicity of ICD-9 Will Be Gone in 2014

Suppose you have a patient claim on your desk with documentation that describes a "right carotid endarterectomy for a critical right internal carotid artery stenosis."

Right now, you can report the right carotid endarterectomy procedure with 38.12 (Endarterectomy of other vessels of head and neck).

However, when you look at your ICD-10-PCS equivalents, you have to have more specific documentation.

Here's What You Need

ICD-10-PCS requires specific information in terms of the type of procedure, the anatomic location/body part, the approach, and the device.

Type of procedure: You need to know whether the right carotid endarterectomy was a "dilation" or "extirpation." A "dilation" means that the procedure expanded an orifice or lumen of a tubular body part. On the other hand, an "extirpation" means that the procedure took or cut out solid matter from a body part.

Anatomic location/body part: Through the "critical right internal carotid artery stenosis" notation, you know that this procedure took place on the right internal carotid artery. That is one area of documentation you don't need to update.

Approach: You do need to know what approach the physician used. Was this open, percutaneous, or percutaneous endoscopic?

Device: Similarly, you need to know what sort of device the physician used--or if she didn't use a device at all. Your options are:

• Intraluminal Device, Drug-eluting
• Intraluminal Device
• No Device

Taking these extra steps in documentation will mean fewer headaches in the future.

Check Out Your ICD-10-PCS Possibilities

According to these limits of available documentation in the patient's medical record, you have the following "Extirpation" or "Dilation" ICD-10-PSC options: