Be Ready for New Procedure Codes

Posted on Oct. 20, 2008

There were 60 new ICD-9-CM procedure codes released this year, effective with discharges on or after Oct. 1. Anyone taking the certified coding specialist (CCS) or physician-based (CCS-P) examinations should ensure they are familiar with the new codes and understand the clinical foundations associated with them. Some of the new codes reflect changing technologies and others represent further detailed differentiation of procedure techniques for existing procedures, such as hernia repairs and breast reconstructive procedures. A short synopsis of the codes and corresponding definitions follows:

SuperSaturated Oxygen Therapy
Code 00.49 represents this new technology, whereby patients with acute myocardial infarctions (AMI) are infused with blood that has been mixed with a small amount of saline and supersaturated with oxygen, to create highly oxygen-rich blood. This treatment has been shown to minimize microvascular damage to the myocardial tissue and is typically used for patients with ST-elevation myocardial infarction (STEMI) AMIs during coronary artery stent placement procedures. The superoxygenated blood is delivered directly to the patient’s stented coronary artery via an infusion catheter. The procedure is performed at bedside in the cardiac catheterization lab. Coding directional guidelines instruct the coder to code also any other coronary artery intervention, along with the number of vessels treated.

Insertion of Intra-Aneurysm Sac Pressure Monitoring Device (Intraoperative)
During endovascular aneurysm repair of both abdominal aortic aneurysms (AAA) and thoracic aortic aneurysms (TAA), one of the most dangerous potential complications is an endoleak, or leaking of blood around the graft itself into the aneurysm sac. This can cause a continued pressure in the sac and put the patient at risk for aneurysm rupture. A new technology called the EndoSure Wireless Pressure Measurement System is used to accurately measure this pressure, while delivering real-time data to the surgeon. Prior to the deployment of a stent graft, pressure measurements are taken within the aneurysm sac and then once again after deployment. By comparing the differences in pressure, the surgeon can determine whether an endoleak is present. The EndoSure is intended to be a permanent implant in the aneurysm sac. Assign procedure code 00.58 when this new technology is documented, along with codes for the primary procedure.

Intravascular Pressure Measurement of Arteries and Other Vessels
New codes in this series were primarily created to allow tracking of coronary fractional flow reserve (FFR), which is a type of intracoronary pressure measurement. FFR uses a pressure sensitive catheter to measure the intravascular pressure distal and proximal to a coronary lesion, which can then be used to assess the functional severity of the lesion, related to the limitation of normal blood flow. It’s usually performed with other invasive or diagnostic cardiac procedures, such as coronary stenting or angioplasty. Use of the pressure sensitive catheter should be documented in the cardiac catheterization lab procedure report. Assign code 00.59 when the procedure is performed on the coronary arteries, 00.67 for intrathoracic arteries, 00.68 for peripheral arteries and 00.69 for other specified and unspecified vessels.

Laparoscopic Repair of Inguinal Hernia
Hernia repair is one of the most common surgeries performed in the U.S. today, and approximately 15 percent of inguinal hernia repairs utilize a laparoscopic approach. The procedure is considered much less invasive than open incisional repair, and consistent with other laparoscopic procedures, healing time is generally shorter, there is less pain and patients may return to work or school sooner than they typically would be able to after open surgery. Because of the lack of space in the ICD-9-CM volume 3 procedure section, a new chapter (3A, Other Miscellaneous Diagnostic and Therapeutic Procedures) and new category (17, Other Miscellaneous Procedures) were created. The laparoscopic hernia repair codes are differentiated by type (indirect vs. direct) and laterality (unilateral or bilateral), just as those for open hernia repair. Because grafts or prostheses are typically performed with the laparoscopic procedures, the new codes include implant placement. Coders should be aware that the open incisional inguinal hernia repair codes in category 53 have also been revised to indicate “other and open” repairs, so each code title is clear in its approach. Assign codes from code range 17.11 through 17.24 for laparoscopic inguinal hernia repair.

Laparoscopic Repair of Other Hernias
As the use of the laparoscopic approach for hernia repair has increasingly included hernia repair involving sites other than the inguinal canal, there is a corresponding need for specific codes representing these procedures. Codes in subcategories 53.4, 53.6 and 53.7 have been expanded to include laparoscopic repair of umbilical, incisional, diaphragmatic and other anterior abdominal wall hernias. Some of these codes are differentiated by the use of a graft or prosthesis, and the diaphragmatic hernias are also differentiated by the approach, whether abdominal or thoracic.

Laparoscopic Colectomy
To avoid abdominal incisions that may range up to 16 inches long, surgeons have developed laparoscopic colectomy procedures that inherently have the same benefits as those listed above in the hernia repair discussion. New codes have been developed to track the different types of procedures and approaches currently used today. In new chapter 3A, seven new codes have been created in category 17 to represent laparoscopic partial excision of the large intestine. Assign a code from range 17.31 through 17.39 for these procedures. In addition, new codes indicating a laparoscopic approach were inserted in existing subcategories or current subcategories were expanded for colectomy procedures. For example, prior to Oct. 1, code 45.8 was assigned for total intra-abdominal colectomy. Code 45.81 is now available to represent a laparoscopic approach, and new codes 45.82 and 45.83 indicate an open approach or other and unspecified approach, respectively. Coders should review new and revised codes in subcategories 45.8, 48.4 and 48.5.

Robotic Assisted Procedures
Six new codes representing robotic assisted procedures were released, primarily for spinal fusion procedures, in which surgeons can percutaneously place pedicle and facet screws via the use of the robotic technology. These procedures were not previously possible, due to prior surgery, difficult anatomy or multi-level disease. The robot is able to visualize and guide the trajectory of the implants, but the surgeon actually places the implant. Correct placement of spinal implants is crucial due to the proximity of the spinal cord, nerve roots, aorta and vena cava. The technology currently available is called SpineAssist and may be used during single or multi-level spinal surgery. This system consists of two units: the robot itself and a workstation for planning, image acquisition and control of the robot. Documentation should include specific information related to the information provided by the robotic workstation. It is thought that these procedures may assist in many procedures performed through a variety of approaches. New codes in the 17.41 through 17.49 range were developed that are differentiated based on surgical approach, including open, laparoscopic, percutaneous, endoscopic, thoracoscopic and other and unspecified. They should be assigned as secondary codes, in addition to the code for the primary procedure.

Endoscopic Pulmonary Airway Flow Measurement
This procedure measures intrapulmonary airflow in patients with various types of lung disease to measure the effectiveness of current treatments and the disease progression. During bronchoscopy, intrapulmonary balloon catheters are inserted into diseased portions of the lung, which identify those areas that could benefit from endobronchial valve therapy (EBV) or lung volume reduction surgery (LVRS). Assign code 33.72 for this adjunct procedure.

Excision or Destruction of LAA
The left atrial appendage (LAA) is located on the wall of the left primary atrium and is a common area of thrombus development in patients with atrial fibrillation. For patients who cannot tolerate oral anticoagulation therapy, surgical clipping, stapling, ligating or oversewing of the LAA is a common treatment to reduce the incidence of stroke. It is performed during other major cardiovascular procedures, such as coronary artery bypass grafting, mitral valve repair or maze procedure. Assign code 37.36 for LAA excision or destruction.

Removal of Internal Biventricular Heart Replacement System
Along with significant revisions to subcategory 37.5, Heart Replacement Procedures, new code 37.55 was created to represent removal of an internal biventricular heart replacement system, which is also known as an artificial heart. Code 37.52 was revised to indicate that the insertion of this type of system includes substantial removal of part or all of the biological heart. Both ventricles are resected, and the native heart is no longer intact. A ventriculectomy should not be coded separately; it is an inherent component of the procedure.

Intravascular Spectroscopy
This procedure involves a fiber optic, catheter-based spectroscopy system designed to characterize the composition of coronary artery plaques for improved determination of the appropriate treatment. The spectroscopy system consists of a laser light source, a small fiber optic catheter, and a console. The system can identify the presence, location and amount of lipid rich plaques in the coronary arteries, and help physicians determine and utilize the most appropriate type of stent. Assign code 38.23 for this procedure.

Repair of the Anulus Fibrosus
The annulus fibrosus is a ring of fibrocartilage and fibrous tissue around the intervertebral disc, surrounding the nucleus pulposus of the spine. During a surgical discectomy, an open pathway or hole is made in the anulus fibrosus, which is then left to heal. The defect is thought to contribute to recurrent disc herniation and a higher rate of reoperations; surgeons are beginning to repair the defect at the time of the initial procedure. Techniques may include microsurgical suture repair with a fascial autograft, soft tissue reapproximation repair with the use of the Xclose Tissue Repair System or surgical mesh repair facilitated by the Inclose Surgical Mesh System. Assign code 80.53 or 80.54 for this adjunct procedure, depending upon whether or not grafting or prosthetic material was utilized.

Total Reconstruction of Breast
Subcategory 85.7 was expanded to include eight new codes representing various surgical techniques for total breast reconstruction, performed after mastectomy. The techniques and their new code assignment include the following:

• Latissimus dorsi myocutaneous flap (85.71): the back’s latissimus dorsi muscle and its overlying skin and fat are raised and rotated into position on the anterior chest wall.

• Transverse Rectus Abdominis Myocutaneous (TRAM) flap (85.72, 85.73): This is the most popular choice for autologous breast reconstruction and involves the use of the rectus abdominis muscle in the abdomen. Its advantages include a dual blood supply, proximity to the breast, and enough bulk to eliminate the need for implants. The two new codes are differentiated by the use of the pedicled or free flap techniques.

• Deep Inferior Epigastric Perforator (DIEP) flap (85.74): this flap is composed of abdominal skin and fat and is based on the deep inferior epigastric vessels, but does not depend on harvest of the rectus muscle as a vascular carrier; the perforating blood vessels are dissected free. The procedure requires microsurgical expertise that typically adds 2 hours to operative time.

• Superficial Inferior Epigastric Artery (SIEA) flap (85.75): This technique is similar to the DIEP flap, using the same abdominal tissue, but the SIEA flap is supplied by the superficial inferior epigastric artery and veins, thus eliminating the need for microvascular dissection. It’s not an option for all patients, since the SIEA and veins are only consistently present in 65 percent of patients.

• Gluteal Artery Perforator (GAP) flap (85.76): This technique involves utilizing skin and fat from the lower buttock region, either the superior gluteal artery perforator (SGAP), or the inferior gluteal artery perforator (IGAP) flap. A significant amount of microdissection is required to isolate the perforating vessels from the surrounding muscle.

• Not otherwise specified and other specified techniques. New code 85.70 should be assigned when the reconstruction is not specified and code 85.79 is assigned for “Other total reconstruction of breast.”


After review of the new procedure codes and all instructional notes and guidelines in the tabular portion of ICD-9-CM volume 3, test your knowledge with the following quiz:

1. The patient was admitted to the hospital for placement of an implantable heart assist device, utilizing a ventricular assist device for a bridge to transplant. The most appropriate ICD-9-CM procedure code is:

a. 37.52

b. 37.62

c. 37.65

d. 37.66

2. A patient who is status post total mastectomy due to breast cancer was seen for total breast reconstruction. The surgeon utilized a portion of the rectus abdominis muscle, which was completely removed from the lower abdomen and moved into place on the anterior chest wall to create the new breast mound. The most appropriate ICD-9-CM procedure code is:

a. 85.73

b. 85.72

c. 85.71

d. 85.79

3. The process by which a patient is infused with highly oxygen-rich blood is known as:

a. Hyperbaric oxygen therapy

b. Nebulizer oxygen therapy

c. SuperSaturated oxygen therapy

d. Oxygen concentrating therapy

4. A patient was scheduled for laparoscopic surgery for a right-sided direct inguinal hernia. At the time of surgery, inspection of the abdomen revealed a left-sided indirect hernia as well, which was also repaired. Before removal of the trocars the surgeon placed surgical mesh on the abdominal wall defect. The most appropriate ICD-9-CM procedure code(s) is/are:

a. 17.11, 17.12

b. 53.13

c. 17.23

d. 17.24

This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix ( Ingenix is a leader in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.

Coding Clinic for ICD-9-CM is published quarterly by the AHA.

1. d. The procedure involved an implantable internal system, ruling out code 37.65, which is an external system and 37.62, which is non-implantable. New code 37.52 should not be assigned because it requires resection of both ventricles and the native heart is no longer intact. Code 37.66 matches the procedural statement most closely, being a heart (ventricular) assist system only.

2. a. Because the procedure involved the rectus abdominis muscle, it is considered a TRAM flap. The procedural statement indicates that the flap was completely removed and moved into place; this is the definition of a free flap; code 85.73 is the most appropriate.

3. c. The process is known as SuperSaturated oxygen therapy and is used for patients with STEMI AMIs during coronary artery stent placement.

4. c. One code is required for repair of bilateral inguinal hernias. The code must reflect a laparoscopic approach, the fact that both direct and indirect hernias were repaired, and that surgical mesh was utilized. Code 17.23 is the most appropriate.