Wiki Complication Codes

[bennieyoung]

I would like to get other opinions if possible...My auditor says If a device is placed for a specific reason (in this case, the Mitra Clip and mitral regurgitation respectively), if the disease returns, it would be considered a complication since the device isn't doing it's job anymore. She wants me to add T82.518A to my diagnosis codes.
As for the T82.518A, I didn't see in the note that there was any complication or failure of the device. They talked about adding a second MitraClip but stated "The MirtaClip was intact and in place."

INDICATIONS FOR PROCEDURES: Severe symptomatic mitral regurgitation.
PROCEDURES:
1. Nonselective left groin sheathogram.
2. 7-French sheath, left common vein.
3. Right heart catheterization with a Swan-Ganz catheter.
4. Bilateral coronary angiography.
5. Left heart catheterization.
6. Left ventriculogram.
HISTORY: Briefly, this is an 84-year-old female with history of known MitraClip with residual mildly severe mitral regurgitation. Patient consented for right and left heart catheterization in anticipation for a 2nd MitraClip.
DESCRIPTION OF PROCEDURE: After informed consent, the patient was brought to BCH, where the patient was prepped and draped in a normal sterile fashion. Using lidocaine, a 6-French sheath, left common artery verified angiographically. A 7-French sheath, left common vein. Through the 7-French sheath, a Swan-Ganz catheter was advanced. Wedge pressure was a mean of 17, A-wave 15, V-wave 30, PA pressure was systolic 42, diastolic 17, mean of 28. RV pressure was systolic 32, diastolic 5, end of 10. RA pressure, mean of 7, A-wave 10, V-wave 9. Cardiac output was measured to be 3.4 by 6 with an index of 2.0. The Swan-Ganz catheter was then removed. A JL4 catheter was then advanced in the left coronary artery. Images of the left coronary artery showed normal long left main, LAD appeared healthy and free of disease. The circumflex system was patent, free of disease with the marginal 1 coming off, which was healthy and free of disease. JL4 catheter was removed. The JR4 catheter was placed into the right coronary artery. Image recording revealed normal os proximal mid-RCA. This appeared to be a right-dominant system. The JR4 catheter was removed. A pigtail catheter was advanced to the left ventricle. EDP was 12 mmHg. Left ventricle in the RAO projection showed EF of 50 to 55% with severe mitral regurgitation. The MitraClip was intact and in place. No pull-back in between the LV and the aorta. The pigtail catheter was removed with a 0.035 wire. Left groin was closed with manual pressure. Patient tolerated the procedure with no complications.
IMPRESSION:
1. Normal coronary arteries.
2. Severe MR with low normal ejection fraction.
3. Mild pulmonary hypertension.
4. Reduced cardiac output.
PLAN: The patient will have 3 hours bed rest. Anticipate discharge later today. Follow up in the office for further discussion of performing a MitraClip in the near future.

 

[thomas7331]

Your auditor's rationale makes no sense. The clip was placed to treat and/or control the condition, so the condition is not also a complication of that treatment. That would be like saying you should code diabetes as a complication of a medication if the patient had a recurrence of high blood sugar again after starting the medication. This is ludicrous. I'm sorry you have to deal with an auditor who thinks this way.

I agree with you, the provider has not documented that this was a complication. And per the ICD-10 guidelines, section I.B.16, in order to code something as a complication, "there must be a cause-and-effect relationship between the care provided and the condition." So, you are correct, you cannot code the condition as a complication because the provider has not stated anywhere here that the MR was caused by the treatment (or failure of the device).