Dissection at time of Stenting

sabullock

When placing a coronary stent sometimes there is a dissection at the end of the stent due to intimal splitting/peeling. This just occurs not due to poor technique, maybe due to vessel disease or just happens. A second stent is then used. Physicians document the dissection and the placement of the second stent. When this occurs do you always code 997.1 cardiac complication and 414.12 dissection of coronary artery. Do you query to ask if it is a complication or is it "assumed"? Is anyone aware of any adverse public reporting of the code 997.1 (Healthgrades/CMS/Others)?

There is a coding clinic (1st Qtr 2011) - if the dissection is stented then we are not querying "if clinical significant" because it was treated.

How are you handling this situation? How have you educated your interventional cardiologist?

Thanks
Shelia Bullock, RN, BSN, MBA, CCM, CCDS
Director, Clinical Documentation Services
University of Mississippi Health Care
2500 North State Street
Room S 336
Jackson, MS 39216
T: 601-815-3079 F: 601-815-9505
sabulllock@umc.edu
umhc.com

ddouthit

Sheila,

The below CC indicates that a query was generated and physician indicated that the dissection was a complication of the stenting. I believe in order to assign 997.1 the physician would need to indicate that the dissection was a complication of the stent.

Dissection of artery occurring during coronary angioplasty

Coding Clinic, First Quarter 2011 Pages: 3-4 Effective with discharges: April 27, 2011

Question:
A patient underwent coronary angioplasty with stent deployment. During the procedure, the patient developed chest pain and ST-segment changes. Angiogram revealed a dissection throughout the proximal mid-portion of the vessel. A Voyager balloon was re-advanced into the vessel and multiple inflations were performed. A stent was advanced into the distal portion of the vessel next to the previously deployed stent with subsequent balloon inflations. A third stent was then advanced in the proximal portion of the vessel with balloon inflation. Additional arteriogram revealed control of the dissection and a widely patent vessel. When queried, the provider indicated that the dissection was a complication of the procedure. Should code 997.1, Cardiac complications, or code 998.2, Accidental puncture or laceration during a procedure, be assigned for complicated dissections occurring during percutaneous transluminal coronary angioplasty (PTCA)? What is the correct diagnosis code assignment for a clinically significant dissection occurring during PTCA?
Answer:
Assign code 997.1, Cardiac complications, since the provider has documented that the dissection was a complication of percutaneous coronary intervention (PCI). Assign code 414.12, Dissection of coronary artery, to further describe the complication.
PCI involves the mechanical dilatation of the artery with compression of atherosclerotic plaque. The manner in which PCI improves luminal diameter is associated with injury to the artery, usually caused by balloon expansion. Mechanical fragmentation of plaque has been associated with distal embolization of plaque debris and vessel dissection. Studies have demonstrated that vessel dissection at the site of PCI is fairly common and can be identified angiographically in approximately 50% of patients immediately following PCI. In most cases, the dissection is minor and clinically insignificant and does not interfere with antegrade blood flow, nor affect the procedural outcome.
Code 998.2, Accidental puncture or laceration during a procedure, is not appropriate since there was no documentation of accidental vessel puncture during the PTCA.
© Copyright 1984-2013, American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.


Dorie Douthit RHIT,CCS
ddouthit@stmarysathens.org