Regulatory Committee insight: Revision versus replacement ICD-10-PCS coding for LVAD

By Joan Oliver, MHA, BSN, RN, ACM, CCDS

CDI professionals, along with HIM professionals, have important responsibilities to assign the most accurate ICD-10-PCS codes to arrive at the correct DRG assignment. Despite working together, there are times when differing perspectives lead to a different DRG. The reconciliation process is a very important part of CDI/HIM collaboration and arriving at the right codes can require tenacity and difficult conversations.

During the transition from ICD-9 to ICD-10, I was a new CDI specialist who often questioned the assigned ICD-10-PCS codes for left ventricular assist device (LVAD) procedures. After much discussion and persistence with both CDI and HIM teams, a finding in the Federal Register and recently published Coding Clinic guidance clarified the specific coding for LVAD procedures.

A LVAD is a mechanical pump implanted in patients with cardiomyopathy, heart failure, or end-stage heart failure either as a bridge to heart transplantation or as destination therapy. The device assists the left ventricle to pump blood out of the ventricle to the aorta and the rest of the body.

After the initial LVAD implantation, a patient may require subsequent procedures for pump replacement due to infection, thrombosis, device malfunction, or revisions to the driveline or pump.

Initially, the implantation of an LVAD requires the surgeon to secure a Dacron inflow graft to the left ventricle and an outflow graft to the ascending aorta. Often during an LVAD replacement, the pump and driveline are replaced without removing the existing inflow and outflow grafts. Removing the sewn grafts from the aorta and left ventricle carries more risk since the tissue is very frail. Therefore, if the secured grafts are not infected, thrombosed, or kinked, the pump is replaced without removal of the grafts.

Knowing which root operation to use for initial and subsequent procedures can be tricky causing consternation between CDI and coding, and have a significant effect on reimbursement. The pump device alone costs upwards of $100,000-plus, which far outweighs any reimbursement an institution will receive for a revision procedure.

By not removing and inserting new inflow and outflow grafts, would the root operation be revision or replacement (removal/insertion)? If the root operation is revision for an LVAD procedure, the DRG assignment would be DRG 215; for a root operation of replacement, you would assign DRG 001-002. (See the boxed codes at the end of this article.). Recent findings in the Federal Register and Coding Clinic can help the coding department select the root operation and ICD-10-PCS codes to assign the correct DRG.

According to the Federal Register, whether the LVAD “pump” itself is removed and replaced is the determining factor if the root operation of the procedure is a revision or a replacement (removal/insertion) stating that “LVAD exchange is when the existing LVAD is removed and replaced with either new LVAD system or new LVAD pump” and further clarifies that an “LVAD revision and repair as the existing LVAD is adjusted or repaired without removing the existing LVAD device.”

Recently, Coding Clinic, first quarter 2019, answered a similar LVAD question as mine on p.24 of the publication. Their answer sheds light on the use of replacement versus revision codes for LVAD procedures. The answer explains not to use a revision root operation when the pump is replaced: “If either the entire heart assist system or the pump is replaced, the appropriate root operations are Removal and Insertion.” This clarification from Coding Clinic will serve as guidance for coding departments to get it right and correctly report costly LVAD procedures.

While I  didn’t receive an answer from Coding Clinic directly, I have submitted two LVAD questions in the past, one of which was very similar to the one answered in the first quarter publication. According to this article from the November/December edition of the CDI Journal, sometimes effecting change takes the efforts of more than one questioner. If you have a question that needs Coding Clinic advice, I encourage you to send it in. It’s more than likely someone else has the same or a similar question and you may just be the voice that tips the scales and gets answers.

Editor’s note: Oliver, a CDI specialist at Duke University in Durham, North Carolina. She is a member of the ACDIS CDI Regulatory Committee. For information about the committee and its work, contact Allen Frady (afrady@acdis.org).