News: Coding Clinic offers guidance on Impella coding

by James S. Kennedy, MD, CCS, CDIP

Coding Clinic for ICD-10-CM/PCS, First Quarter 2017, which became effective March 15, provides interesting perspectives regarding coding and documentation for Impell®, an implantable heart pump device that supports a patient’s circulation and, when implanted or removed, has a significant effect on MS-DRGs or APR-DRGs.

On the other hand, the ICD-10-PCS performance codes for Impella [5A0-] may have a different effect, or no effect at all, if not paired with an Impella insertion or removal code. Learn more about Impella here.

This advice in Coding Clinic, First Quarter 2017, pp. 10–14, makes it very clear that the insertion of an Impella device cannot be coded if it occurs after the start of a procedure and then is removed prior to or at the end of the procedure. The issue states (emphasis added): “Assign a code for the assistance only [5A0] when an external heart assist device such as the Impella is inserted intraoperatively and removed at the completion of the procedure. It would not be appropriate to assign a code for the insertion of the device.”

Coding Clinic emphasizes that “this is consistent with ICD-10-PCS guideline B6.1a which states that a device is coded only if a device remains after the procedure is ended.” In support, it also states that, “according to the National Quality Forum, ‘Surgery ends after all incisions or procedural access routes have been closed in their entirety, device(s) such as probes or instruments have been removed, and, if relevant, final surgical counts confirming accuracy of counts and resolving any discrepancies have concluded and the patient has been taken from the operating/procedure room.’”

Coding Clinic does allow us to code the insertion and/or removal of an Impella device if its removal occurs outside the confines of a surgical procedure. On p. 11, it states that these codes are assigned when an Impella device, implanted during surgery, is left in for a few hours postoperatively. In this case, Coding Clinic suggests that the following codes would be assigned:

• 02HA3RZ, insertion of external heart assist system into heart, percutaneous approach
• 02PA3RZ, removal of external heart assist system from heart, percutaneous
• 5A0221D, assistance with cardiac output using impeller pump, continuous

Coding Clinic reiterates this on pp. 11–12 when it advises the following codes for implantation of right- and left-side Impella devices with a percutaneous coronary intervention, with the left-side device being removed prior to the end of the procedure and the right-side device being left in for several days:

• 02HA3RS, insertion of biventricular external heart assist system into heart, percutaneous approach (for the insertion of the biventricular external heart assist device)
• 02PA3RZ, removal of external heart assist system from heart, percutaneous approach (for the removal of the right-side device—note that Coding Clinic does not allow a code for the removal of the left-side device, since its removal occurred prior to the end of the procedure)
• 5A0221D, assistance with cardiac output using impeller pump, continuous (for the assistance with the impeller pump)

I found it interesting that Coding Clinic explicitly states that this advice applied only to Impella and not to other devices, such as Swan-Ganz catheters or intra-aortic balloon pumps. Does this guidance indicate there are devices that can be implanted during surgery, removed prior to the end of surgery, and still be coded? I suggest that this issue be discussed with your inpatient coders.

Editor’s note: Kennedy is a general internist and certified coder specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at jkennedy@cdimd.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries. This article was originally published in JustCoding.