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Scenario Week of April 23, 2014:
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Assign the correct codes for the following scenario using ICD-9-CM diagnosis and procedure codes, ICD-10-CM and ICD-10-PCS codes:

History of Present Illness: The patient is a 47-year-old woman who was first seen at this hospital over a month ago complaining of abdominal pain. On chest x-ray, she had a possible infiltrate, and it was thought she might have pneumonia and was treated with antibiotics and prednisone. Symptoms improved temporarily, but did not completely resolve. Her pain eventually worsened, and she returned to the ER where an ultrasound was done. It was noted that her spleen was enlarged at 19 cm. She underwent positron emission tomography (PET) scanning, which showed diffuse hypermetabolic lymph nodes measuring 1–2 cm in diameter, as well as a hypermetabolic spleen that was enlarged. The patient underwent lymph node biopsy on the right neck, pathology consistent with mantle cell lymphoma.

Impression: The patient is being admitted for initiation of chemotherapy to treat newly diagnosed mantle cell lymphoma. Treatment will consist of hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone. Toxicities have already been discussed with her including bladder toxicity, myelosuppression, mucositis, diarrhea, nausea, the low risk for cardiac toxicity, neuropathy, constipation, etc. Written materials were provided to her last week.

Informed Consent: The risks, benefits, and reasonable alternatives of the procedure were explained to the patient, who elected to proceed with the procedure.

Preoperative Diagnosis: Mantle cell lymphoma

Postoperative Diagnosis: Mantle cell lymphoma

Procedure Performed: Percutaneous placement of Port-A-Cath via the right subclavian vein

Surgeon: John Doe, MD

Anesthesia: Local using 1% Carbocaine solution with intravenous Versed sedation

Estimated blood loss: 15 mL

Complications: None

Details of Procedure: The patient was transported to the operating room and placed supine on the operating table. Following administration of intravenous Versed to achieve a satisfactory level of anesthesia, the right chest, neck, and supraclavicular fossa were prepped and draped in a customary fashion. A site was selected along the right anterior chest wall for the planned pocket for the port. The skin was thoroughly infiltrated with 1% Carbocaine solution and a transverse skin incision made. The dissection was carried into the subcutaneous tissue, and a pocket fashioned using sharp and blunt dissection. With the patient in the Trendelenburg position, utilizing the provided introducer needle, the right subclavian vein was cannulated. A guidewire was passed without difficulty, and the needle was removed. Fluoroscopy confirmed satisfactory position of the guidewire in the right atrium.

A dilator and sheath was passed over the guidewire. The guidewire and dilator were removed, the catheter was inserted through the sheath and the sheath was carefully withdrawn. Fluoroscopy again confirmed satisfactory position of the catheter, and the catheter under fluoroscopic guidance was retracted into the superior vena cava. The catheter had been preflushed with dilute heparin solution (100 units/mL). The port, which had been preflushed with saline, was attached to the catheter. The catheter and port were secured with 2-0 Prolene suture. Site was irrigated with saline. Hemostasis was verified. The insertion site along the right clavicle was closed with a single stitch of 3-0 Vicryl in the subcutaneous tissue. Benzoin and Steri-Strips as well as a Tegaderm dressing were placed across the incisions.The patient tolerated the procedure well and left the operating room in good condition. A chest x-ray was obtained to ensure proper placement without evidence of pneumothorax.

Please assign the correct ICD-9-CM and ICD-10-CM/PCS codes for the procedure above.


ICD-9-CM Diagnosis and Procedure Codes
V58.11 Encounter for antineoplastic chemotherapy
200.41 Mantle cell lymphoma, lymph nodes of head, face and neck
789.2 Splenomegaly
86.07 Insertion of totally implantable vascular access device [VAD]
99.25 Injection or infusion of cancer chemotherapeutic substance

Patient was admitted for Port-a-Cath insertion to initiate chemotherapy for newly diagnosed mantle cell lymphoma. Section I.C.2.e.2. of the Official ICD-9-CM Guidelines for Coding and Reporting states, “if a patient admission/encounter is solely for administration of chemotherapy assign code V58.11, Encounter for antineoplastic chemotherapy as the first-listed or principal diagnosis.” The malignancy would then be coded as a secondary diagnosis based on this same guideline. The mantle cell lymphoma can be accessed in the ICD-9-CM index by Lymphoma, mantle cell 200.4. Review of the tabular list for code 200.4 shows that a 5th digit is needed to identify the site of the lymphoma. The biopsy that was performed during a previous admission was of lymph nodes in the neck region, and pathology confirmed lymphoma. A 5th digit of 1 for code 200.4 describes mantle cell lymphoma of the lymph nodes of head, face, and neck.

Although the PET scan showed a hypermetabolic spleen, there is insufficient documentation linking the lymphoma to the spleen; therefore, code 200.47 Mantle cell lymphoma of the spleen, should not be coded as a secondary diagnosis. In order to identify the symptoms related to the enlarged spleen, code 789.2 for splenomegaly, could be added as a secondary diagnosis.

Coding for the percutaneous insertion of Port-a-Cath is found through the ICD-9-CM procedure index entry Insertion, port, vascular access or Insertion, vascular access device, totally implantable 86.07. The tabular list should be consulted to confirm that assignment of code 86.07 is appropriate. The chemotherapeutic agents that were initiated this visit would be represented by code 99.25 found in the ICD-9-CM procedure index under Chemotherapy, for cancer NEC.

ICD-10-CM Diagnosis and ICD-10-PCS Procedure Codes
Z51.11 Encounter for antineoplastic chemotherapy
C83.11 Mantle cell lymphoma, lymph nodes of head, face, and neck
R16.1 Splenomegaly, not elsewhere classified
02HV33Z Insertion of infusion device, superior vena cava, percutaneous approach
0JH63XZ Insertion of vascular access device into chest subcutaneous tissue and fascia, percutaneous approach
3E04305 Introduction of other antineoplastic substance into central vein, percutaneous approach

Assign code Z51.11 Encounter for antineoplastic chemotherapy, as the first-listed or principal diagnosis. ICD-10-CM guidelines are very similar to the ICD-9-CM guidelines regarding admission for chemotherapy. Section I.C.2.a. states, “if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy, assign the appropriate Z51.- code as the first-listed or principal diagnosis.” This guideline further specifies as does an instructional note found under category Z51 to code also the condition requiring care.

The condition requiring the initiation of chemotherapy is the mantle cell lymphoma. Mantle cell lymphoma can be located in the ICD-10-CM index under Lymphoma, mantle cell C83.1. Upon review of the tabular list, code C83.1 can be further classified at the 5th digit level by identifying the site of the lymphoma — a 5th digit of 1 would be assigned to designate the lymph nodes of the head, face, and neck. Splenomegaly, without further documentation as to type, codes to R16.1 Splenomegaly, not elsewhere classified.

For this scenario two separate procedures are needed for proper coding of a Port-a-Cath insertion: one code to identify the insertion of the catheter and a second code to identify the insertion of the port. For the catheter insertion, AHA Coding Clinic 1Q13 instructs coders to report the “end placement of the catheter, meaning the site where the device ended up.” Although the guidewire was placed into the right atrium the actual catheter was retracted into the superior vena cava. Using the index, “Insertion of device in, vena cava, superior” identifies table 02H and body site character V for the superior vena cava. Upon review of the table, the code can be further specified with 5th character 3 for percutaneous approach, 6th character 3 for infusion device, and 7th character of Z no qualifier.

The insertion of the port is also accessed through the main term “Insertion of device in.” The procedure notes indicate the insertion of the port is in the subcutaneous tissue of the right chest; therefore, under “Insertion of device in” locate the subterms subcutaneous tissue and fascia, chest. Table 0JH is identified along with the 4th character 6 for the body site. Again the procedure was performed percutaneously, so the 5th character for approach would be 3. The device character for this scenario is X, vascular access device. The device character of W, vascular access device, reservoir is not appropriate based on AHA Coding Clinic 4Q13, which states that the reservoir on a Port-a-Cath is “small and not used to store medicine during the course of treatment.” The 7th character is Z no qualifier.

The infusion of the chemotherapeutic agents is captured in the administration section of ICD-10-PCS by the root operation of Introduction. Access the ICD-10-PCS index main term and subterms “Introduction of substance in or on, vein, central, antineoplastic” to identify table 3E0 and body site character 4 for central vein. Review table 3E0 to determine the 5th–7th characters.

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