Coding Clinic Advice: Endoscopic Banding of Esophageal Varices (Q4 2013)

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Coding Clinic, published by AHA Central Office, is the official publication endorsed by CMS for coding guidelines and advice. Coding Clinic provides specific information and guidelines that are helpful for determining proper coding.

These videos by Barry Libman, MS, RHIA, CDIP, CCS, CCS-P, offer a discussion of selected topics from recent issues of Coding Clinic (both ICD-9 and ICD-10). (Lectures were recorded during the 2014 GHIMA Annual Meeting and Exhibit on 8/21/2014.)

Next, we have a rather complex question.

And you can tell because the next six
slides are gonna be devoted to both

the question and the answer.

So let's go through this slowly.

And it starts with a clinical situation.

A patient with hematemesis presents for
an EGD.

The patient is found to have esophageal
varices, and therefore, ligation of those

esophageal varices is performed using
bands placed via a band ligation device.

The question starts out by saying,

what is the appropriate ICD-10-PCS
body system for esophageal varices,

is it the gastrointestinal system or
is it lower veins?

And right off the bat it gives you pause
because that's a very odd question for

Coding Clinic to be asking.

The questioner goes on to point out,
in ICD-10-PCS,

ligation is coded to the root
operation occlusion.

Therefore, if we use table 06L, and
you'll recall from your training,

that 0 is the med-surg section,
6 is lower veins, and L is occlusion.

If we use 06L for
occlusion of the lower veins,

there is the appropriate body part and
a device value for the bands.

I wanna stop right there and say, one
of the questions everyone has is you're

talking about the esophageal vein, why
would it be classified as a lower vein?

Because we know that the rule is the
dividing point in the body for upper and

lower is the diaphragm.

And the fact of the matter
is that oddly enough,

if you look it up, the esophageal
vein originates below the diaphragm.

Hence, making it technically a lower vein.

And that's not a point that we
get to debate, that's part of

ICD-10 structure and Coding Clinic,
in fact, supports that.

However, there's two problems with this
supposition made by the questioner.

However, there is no approach value for

via natural or
artificial opening endoscopic.

However, if we use 0DL, the table for

occlusion of the gastrointestinal system
and use esophagus for the body part,

there is the appropriate approach value,
but there was no device option.

So here's the real question.

What is the appropriate
ICD-10-PCS code assignment for

endoscopic banding of esophageal varices,

given the problems posed by
the person presenting the question?

And you know that you're in a little
bit of trouble when, in the course of

answering the question, Coding Clinic
starts out by giving an anatomy lesson.

Esophageal varices are enlarged
veins of the esophagus,

which can spontaneously rupture and
cause severe bleeding.

Endoscopic banding of these esophageal
varices involves completely occluding

the blood flow and meets the root
definition of the operation occlusion.

The lumen of the esophageal vein is
being banded, not the esophagus.

So you start to get a sense of
the direction that they're going in with

their answer.

The index under ligation states,
see occlusion.

And this is actually a good time to
point out that the index in the PCS

classification is really
an exquisite document.

It does a lot of translation
of things as you see here.

Turning ligation,
if you don't know the root operation,

sending you to see occlusion.

But here is the answer.

Assign the following ICD-10-PCS code.

06L34CZ, 0 is the med-surg section,

6 is the lower vain, L is occlusion,
3 is the esophageal vein,

4 is the approach percutaneous endoscopic,

C tells us the device the bands and Z,
tells us that there is no qualifier.

The next paragraph goes on to
defend the answer, the ICD-10-PCS

tables currently do not use
approaches containing the phrase,

via natural or artificial opening, for
body parts in the cardiovascular system.

And basically what this paragraph tells us
is that there is an oversight in the PCS

classification that doesn't allow us to
code this one correctly using ICD-10-PCS.

The answer goes on to point out
that the use of this approach for

blood vessel body parts could change over
time if requests for additional codes

are made through the ICD-10-PCS
Coordination and Maintenance process.

Basically the answer that's being provided
to us is that because there is no code,

the advice is to use the wrong code
until the problem is corrected.

Not unlike the discussion we had
about diabetes a little bit earlier.

And I reiterate that, well, this is mostly
to bring these problems to your attention.

And, again, I completely mean that this is
not a criticism of the classification per

se but I wanna bring these to your
attention because this like diabetes

that we talked about earlier,
a common link with ketoacidosis,

a commonly reported condition.

This is going to be a commonly
reported procedure and

we need to have a means by which to report
it until the situation gets corrected.

But as your curious coders would always
do, you would run these codes through

the grouper to see what
the reimbursement implications might be.

In ICD-9, you see what the codes are,
you recognize those alcoholic cirrhosis,

bleeding esophageal varices,
which is a major comorbid condition,

endoscopic ligation of esophageal varices,
procedure code 42.33,

giving you a reasonable weight of 1.7150.

But if you run these same codes through
the ICD-10 grouper, this is what you get,

you get DRG 981 that has
a cost weight of 4.9.

Bit of an aberration, but
wanted to bring that to your attention.

Also wanted to comment that this
was done using grouper version

31 that is currently available
to look up ICD-10 codes.

We're told that there is a version 31r,
a revised

version of the ICD-10 grouper,
that's due out any day.

I would recommend, and I will certainly
personally check this out to see if this

is one of the groupings that
will be revised at that point.

But I do wanna bring
that to your attention.