Ask the Expert

This month’s selection:

We have three general questions:

1. How would an interscalene pain block of a nerve post orthopedic procedure be coded? Currently in ICD-9 we use 04.81, injection of an anesthetic, or 04.81, 04.89 and 99.23 if it is a combination of anesthetic and steroid with CPT 64415 and an X modifier added to the CPT code.

2. Would it be appropriate to add a code for the facial nerve monitoring done during a procedure removing a parotid tumor? ICD-10-PCS manual notes under the Measurement and Monitoring Section: “If a device used to perform the measurement is inserted and left in, then insertion of the device is coded as a separate Medical and Surgical procedure.”

*There is no device left in for the monitoring after procedure completion, so are we correct to assume this would not be an added surgical procedure code?

3. Also, in a loop electrosurgical excision procedure (LEEP), would the qualifier be and X or a Z when a Conization is performed?

Colleen Braun, CCS
Toms River, New Jersey

Response:

1. The ICD-10-PCS codes for an interscalene pain block are decided by the intent of the injection (local anesthesia or regional anesthesia). The code is located in the 3E0 table. Typically, this procedure is performed on the peripheral nervous system; therefore, 3E0T3—will begin the coding selection.

Part 2 of the question relates to clarification of coding a combination of anesthetic and steroid. This question was clarified in 4th Quarter 2014 of Coding Clinic. See below.

Question: What is the appropriate ICD-10-PCS code, when a combination of drugs is administered during a single injection (eg, corticosteroid and local anesthetic)?

Answer: If two substances are combined into a single injection, and the facility desires to collect this information, the introduction of both substances may be coded. The administration of substances can be found in section 3 of ICD-10-PCS.

2. Use of PCS devices is explained fully in the ICD-10-PCS Reference Manual. It is recommended that a coder should ask him- or herself, “Is this material central to achieving the objective of the procedure, or does it only support the performance of the procedure?”

The monitoring device would not be assigned an ICD-10-PCS code.

3. ICD-10-PCS uses the qualifier value “X” to identify when a procedure is performed for diagnostic purposes vs a “Z” for therapeutic. Research of the LEEP on the Johns Hopkins website revealed the following:

“With LEEP, an electric current passes through the fine wire loop to cut away a thin layer of abnormal tissue. This tissue will be sent to the lab for examination. LEEP can also remove abnormal cells to allow healthy tissue to grow.”

The selection of the qualifier will be determined by the documentation in the medical record. Did the surgeon remove the tissue for diagnostic purposes (qualifier X) or for treatment (such as eliminating the abnormal cells to allow for healthy tissue to grow)?

Coders are cautioned not to select the qualifier value of “X” for every specimen that is sent to pathology. Surgical protocol requires that all specimens removed during surgery must be submitted to surgical pathology for gross and/or microscopic examination. The decision making for selecting the qualifier “X” (diagnostic) is determined by documentation that states the objective of the procedure was diagnostic.