Coronary Arteries: Number of Vessels/Number of Stents
Issue
Should code table 027 be revised to capture the number of coronary vessels treated and/or the
number of coronary stents inserted?
New Technology Application
No
Background
Since FY 2006, ICD-9-CM has had adjunct codes to identify the number of vessels treated in a
procedure (00.40-00.43) as well as the number of vascular stents inserted (00.45-00.48). As
intended, it has been useful to collect this data for outcomes analysis and also to adequately
capture hospital resource use. It is also notable that the impetus to create these codes arose
from a discussion in the FY 2005 HIPPS final rule (69 Federal Register 48974) on the need to
identify insertion of stents in multiple vessels or insertion of multiple stents.
ICD-10-PCS, however, does not contain adjunct codes. Instead, ICD-10-PCS users must
currently make assumptions about the number of vessels and stents from the Body Part for
coronary artery "site" in code table 027-Dilation of Heart and Great Vessels. However, the only
assumptions possible with the current code structure are too broad, and do not accurately
capture the number of coronary vessels and stents. Precisely because they are inaccurate,
Coding Clinic (4th Q 2005) has also advised coders not to make these types of assumptions.
Coding Options
The current code table 027 is below:
Section;
0 Medical and Surgical
Body System:
2 Heart and Great Vessels
Operation:
7 Dilation: Expanding an orifice or the lumen of a tubular body part
Body Part
Approach
Device
Qualifier
0
1
2
3
0 Open
3 Percutaneous
4 Percutaneous
Endoscopic
4 Intraluminal Device, Drug-eluting
D Intraluminal Device
T Intraluminal Device, Radioactive
Z No Device
6 Bifurcation
Z No Qualifier
Coronary Artery, One Site
Coronary Arteries, Two Sites
Coronary Arteries, Three Sites
Coronary Arteries, Four or More Sites
There are several options for capturing the number of coronary vessels, capturing the number
coronary of stents, or capturing both.
Number of coronary vessels
Capturing the number of coronary vessels involves changes to the characters for Body Part in
code table 027. Currently, the coronary arteries are classified by the number of distinct "sites"
treated, rather than by the anatomic name of each coronary artery or the number of coronary
arteries.
 Anatomic name
Using the anatomic name of each coronary artery as the body part would lead to an unwieldy
profusion of codes and is not presented as an option.
 Number of coronary vessels
Classifying by the number of coronary arteries will limit the number of codes while allowing for a
direct count of the number of vessels. This type of classification is already familiar to coders
and, with corresponding guidelines on which specific coronary vessels to count, will be
unambiguous.
In addition to code table 027, there are three other code tables in Body System 2-Heart and
Great Vessels which use coronary arteries as a Body Part. They are: code table 021-Bypass;
code table 02C-Extirpation; and code table 02Q-Repair. Defining the Body Part by the number
of coronary arteries rather than by "site" does not disrupt use of these other tables. Also, the
ICD-9-CM precedent for Bypass already makes using the number of coronary arteries familiar to
coders.
 No changes
Because the primary focus is on stents, leaving the Body Part unchanged may simplify the
revisions. This would also leave tables 021, 02C and 02Q unchanged.
Number of coronary stents
Capturing the number of coronary artery stents can be accomplished by revising the Device
character or the Qualifier character in code table 027. These changes allow a direct count.
 Device character
The existing Device values for "intraluminal device, drug-eluting" and "intraluminal device"
describe drug-eluting stents and bare metal stents. By adding Device values that are currently
open in Body System 2- Heart and Great Vessels, the Device character can be expanded to
show the number of stents. This adheres to the ICD-10-PCS principle of describing devices
within the Device column while also allowing for the bifurcation qualifier to be appended to the
resulting procedure codes.
Existing device values 4-intraluminal device, drug-eluting and D-intraluminal device are left
unchanged. This allows these values to be assigned for one stent and when the number of
stents is unspecified. It also allows these existing values to be assigned when collecting the
number of stents is not applicable, for example in other code tables in Body System 2-Heart and
Great Vessels which also use Device values 4-intraluminal device, drug-eluting and Dintraluminal device. These other code tables are: 021-Bypass, 02H-Insertion, 02L-Occlusion,
02P-Removal, 02V-Restriction, and 02W-Revision.
As proposed, expanding the Device character to show the number of stents would be limited to
code table 027-Dilation. However, if it was later seen as desirable to collect the number of
intraluminal devices for one or more of these other code tables, the structure proposed for code
table 027 could easily be adopted.
 Qualifier character
Rather than altering the Device values, the number of stents can be shown by expanding the
Qualifier values. This limits the revisions to code table 027, rather than crossing over to other
code tables. It also allows the use of language already familiar to coders from ICD-9-CM and
differentiates stents from any other intraluminal devices. Finally, it conserves Device values
that may be needed in the future. However, this option means that a single code could not be
assigned that identifies both the number of stents and bifurcation, because both are shown by
qualifiers. A second code could be assigned for bifurcation, but this could complicate data
analysis. Alternately, bifurcation could simply not be identified in these cases.
Option 1 - Number of coronary vessels and stents (Device character)
Section:
0 Medical and Surgical
Body System:
2 Heart and Great Vessels
Operation:
7 Dilation: Expanding an orifice or the lumen of a tubular body part
Body Part
Approach
Device
Qualifier
0
1
2
3
0 Open
3 Percutaneous
4 Percutaneous
Endoscopic
4 Intraluminal Device, Drug-eluting
5 Intraluminal Device, Drug-eluting, Two
6 Intraluminal Device, Drug-eluting, Three
9 Intraluminal Device, Drug-eluting, Four or More
D Intraluminal Device
E Intraluminal Device, Two
F Intraluminal Device, Three
G Intraluminal Device, Four or More
T Intraluminal Device, Radioactive
Z No Device
6 Bifurcation
Z No Qualifier
Coronary Artery, One
Coronary Arteries, Two
Coronary Arteries, Three
Coronary Arteries, Four or More
Option 2 - Number of coronary vessels and stents (Qualifier character)
Section:
0 Medical and Surgical
Body System:
2 Heart and Great Vessels
Operation:
7 Dilation: Expanding an orifice or the lumen of a tubular body part
Body Part
Approach
Device
Qualifier
0
1
2
3
0 Open
3 Percutaneous
4 Percutaneous
Endoscopic
4 Intraluminal Device, Drug-eluting
D Intraluminal Device
T Intraluminal Device, Radioactive
Z No Device
1 Insertion of one vascular
stent/ unspecified number
of stents
2 Insertion of two vascular
stents
3 Insertion of three
vascular stents
4 Insertion of four or more
vascular stents
6 Bifurcation
Z No Qualifier
Coronary Artery, One
Coronary Arteries, Two
Coronary Arteries, Three
Coronary Arteries, Four or More
Option 3 - Number of coronary stents only (Device character)
Section:
0 Medical and Surgical
Body System:
2 Heart and Great Vessels
Operation:
7 Dilation: Expanding an orifice or the lumen of a tubular body part
Body Part
Approach
Device
Qualifier
0 Coronary Artery, One Site
1 Coronary Arteries, Two Sites
2 Coronary Arteries, Three Sites
3 Coronary Arteries, Four or More
Sites
0 Open
3 Percutaneous
4 Percutaneous
Endoscopic
4 Intraluminal Device, Drug-eluting
5 Intraluminal Device, Drug-eluting, Two
6 Intraluminal Device, Drug-eluting, Three
9 Intraluminal Device, Drug-eluting, Four or More
D Intraluminal Device
E Intraluminal Device, Two
F Intraluminal Device, Three
G Intraluminal Device, Four or More
T Intraluminal Device, Radioactive
Z No Device
6 Bifurcation
Z No Qualifier
Option 4 - Number of coronary stents only (Qualifier character)
Section:
0 Medical and Surgical
Body System:
2 Heart and Great Vessels
Operation:
7 Dilation: Expanding an orifice or the lumen of a tubular body part
Body Part
Approach
Device
Qualifier
0 Coronary Artery, One Site
1 Coronary Arteries, Two Sites
2 Coronary Arteries, Three Sites
3 Coronary Arteries, Four or More
Sites
0 Open
3 Percutaneous
4 Percutaneous
Endoscopic
4 Intraluminal Device, Drug-eluting
D Intraluminal Device
T Intraluminal Device, Radioactive
Z No Device
1 Insertion of one vascular
stent/ unspecified number
of stents
2 Insertion of two vascular
stents
3 Insertion of three
vascular stents
4 Insertion of four or more
vascular stents
6 Bifurcation
Z No Qualifier
Peripheral Arteries: Number of Stents and Bifurcation
Issue
Should code tables 037 and 047 be revised to capture the number of stents inserted and to
capture treatment of vessel bifurcations?
New Technology Application
No
Background
As with coronary arteries, ICD-10-PCS does not provide a means to identify the number of
peripheral vessels treated in a procedure or the number of peripheral stents inserted.
For peripheral, it's less essential to change the code table to capture the number of vessels
treated. This is because, for the most part, ICD-10-PCS enumerates peripheral vessels
individually by name and often by laterality as well. Even when it doesn't, ICD-10-PCS
guidelines state that the same code is assigned multiple times for interventions in different
vessels that use the same body part (eg, because the common femoral artery, external femoral
artery and superficial femoral artery all use the body part Femoral Artery, the same code would
be assigned three times for dilation of all three vessels during the same encounter). So it is
possible to capture the number of vessels with reasonable accuracy by totaling the number of
codes assigned.
However, the number of peripheral stents inserted cannot be accurately captured without
changes to code tables 037-Dilation of Upper Arteries and 047-Dilation of Lower Arteries.
Further, although available in ICD-9-CM and present on coronary artery Dilation table 027, the
ability to identify treatment of a vessel bifurcation is not currently possible for peripheral artery
Dilation tables 037 or 047. Restoring this information will allow data collection at the current
level of detail and will also provide consistency between coronary and peripheral arteries within
ICD-10-PCS.
Coding Options
The changes being requested for peripheral vessels allow a direct count of stents, rather than
assumptions. Directly counting the number of stents is already familiar to coders in ICD-9-CM.
Number of peripheral artery stents
Capturing the number of peripheral stents can be accomplished by the same options in the
Device and Qualifier characters for peripheral artery code tables 037 and 047 as are being
proposed for coronary artery code table 027.
 Device character
The same device values proposed for coronary artery table 027 are also open in Body System
3-Upper Arteries and Body System 4-Lower Arteries. Using the same values maintains
consistency throughout the classification.
As with the coronary artery proposal, existing device values 4-intraluminal device, drug-eluting
and D-intraluminal device are left unchanged. These values can be assigned for one stent and
when the number of stents is unspecified. They can also be assigned when the number of
stents is not applicable for other code tables which use the intraluminal device values: 03H and
04H-Insertion, 03L and 04L-Occlusion, 03P and 04P-Removal, 03V and 04V-Restriction, and
03W and 04W-Revision.
 Qualifier character
Again, using Qualifier values to show the number of stents limits the impact to code tables 037
and 047, uses language already familiar to coders, differentiates stents from other intraluminal
devices, and conserves Device values. However, a single code could not identify both the
number of stents and bifurcation, because both are shown by qualifiers.
Bifurcation
Similar to coronary artery table 027, a Qualifier for bifurcation would be added to peripheral
artery tables 037 and 047. If the number of stents is also shown by a Qualifier, as in Option 2,
either a second code could be assigned for bifurcation, or bifurcation could simply not be
identified in these cases.
Option 1 - Number of peripheral stents (Device character) and bifurcation (Qualifier)
Section:
0 Medical and Surgical
Body System: 4 Lower Arteries
Operation:
7 Dilation: Expanding an orifice or the lumen of a tubular body part
Body Part
Approach
Device
0 Abdominal Aorta
1 Celiac Artery
2 Gastric Artery
3 Hepatic Artery
4 Splenic Artery
5 Superior Mesenteric Artery
6 Colic Artery, Right
7 Colic Artery, Left
8 Colic Artery, Middle
9 Renal Artery, Right
A Renal Artery, Left
B Inferior Mesenteric Artery
C Common Iliac Artery, Right
D Common Iliac Artery, Left
0 Open
3 Percutaneous
4 Percutaneous
Endoscopic
4 Intraluminal Device, Drug-eluting
5 Intraluminal Device, Drug-eluting, Two
6 Intraluminal Device, Drug-eluting, Three
9 Intraluminal Device, Drug-eluting, Four or More
D Intraluminal Device
E Intraluminal Device, Two
F Intraluminal Device, Three
G Intraluminal Device, Four or More
Z No Device
Qualifier
6 Bifurcation
Z No Qualifier
Option 2 - Number of peripheral stents (Qualifier character) and bifurcation (Qualifier)
Section:
0 Medical and Surgical
Body System: 4 Lower Arteries
Operation:
7 Dilation: Expanding an orifice or the lumen of a tubular body part
Body Part
Approach
Device
Qualifier
0 Abdominal Aorta
1 Celiac Artery
2 Gastric Artery
3 Hepatic Artery
4 Splenic Artery
5 Superior Mesenteric Artery
6 Colic Artery, Right
7 Colic Artery, Left
8 Colic Artery, Middle
9 Renal Artery, Right
A Renal Artery, Left
B Inferior Mesenteric Artery
C Common Iliac Artery, Right
D Common Iliac Artery, Left
0 Open
3 Percutaneous
4 Intraluminal Device, Drug-eluting
D Intraluminal Device
Z No Device
1 Insertion of one vascular
stent/ unspecified number of
stents
2 Insertion of two vascular
stents
3 Insertion of three vascular
stents
4 Insertion of four or more
vascular stents
6 Bifurcation
Z No Qualifier
4 Percutaneous
Endoscopic
Coronary and Peripheral Artery Extirpation: Bifurcation
Issue
Should coronary code table 02C and peripheral artery code tables 03C and 04C be
revised to capture treatment of vessel bifurcations?
New Technology Application
No
Background
Since FY 2007, ICD-9-CM has had adjunct code 00.44 to identify treatment of vessel
bifurcation. This has been useful for data collection and analysis as well explaining
hospital resource use.
In ICD-9-CM usage, bifurcation code 00.40 can be used with primary codes for
angioplasty, stent insertion and atherectomy.
In ICD-10-PCS, bifurcation is only currently available as a Qualifier for code table 027Dilation of Heart and Great Vessels. A Qualifier for bifurcation has been separately
requested for code tables 037-Dilation of Upper Arteries and 047-Dilation of Lower
Arteries. This request is to add a Qualifier for bifurcation to the codes tables for
coronary and peripheral artery Extirpation. Doing so will restore the ability to capture
treatment of vessel bifurcations for atherectomy (Extirpation) in addition to
angioplasty and stenting (Dilation).
Coding Options
Add a Qualifier for bifurcation to code tables 02C, 03C and 04C.
Code Table 02C-Extirpation of Heart and Great Vessels
Section;
Body System:
Operation:
Body Part
0 Medical and Surgical
2 Heart and Great Vessels
C Extirpation: Taking or cutting out solid matter from a body part
Approach
Device
Qualifier
0
1
2
3
Coronary Artery, One Site
Coronary Arteries, Two Sites
Coronary Arteries, Three Sites
Coronary Arteries, Four or More Sites
0 Open
3 Percutaneous
4 Percutaneous
Endoscopic
Code Table 03C-Extirpation of Upper Arteries
Section:
0 Medical and Surgical
Body System: 3 Upper Arteries
4 Intraluminal Device, Drug-eluting
D Intraluminal Device
T Intraluminal Device, Radioactive
Z No Device
6 Bifurcation
Z No Qualifier
Operation:
C Extirpation: Taking or cutting out solid matter from a body part
Body Part
Approach
Device
Qualifier
0 Internal Mammary Artery, Right
1 Internal Mammary Artery, Left
2 Innominate Artery
3 Subclavian Artery, Right
4 Subclavian Artery, Left
5 Axillary Artery, Right
6 Axillary Artery, Left
7 Brachial Artery, Right
8 Brachial Artery, Left
9 Ulnar Artery, Right
A Ulnar Artery, Left
B Radial Artery, Right
C Radial Artery, Left
D Hand Artery, Right
F Hand Artery, Left
G Intracranial Artery
H Common Carotid Artery, Right
J Common Carotid Artery, Left
0 Open
3 Percutaneous
4 Percutaneous
Endoscopic
4 Intraluminal Device, Drug-eluting
D Intraluminal Device
Z No Device
6 Bifurcation
Z No Qualifier
Code Table 04C-Extirpation of Lower Arteries
Section:
0 Medical and Surgical
Body System: 4 Lower Arteries
Operation:
C Extirpation: Taking or cutting out solid matter from a body part
Body Part
Approach
Device
Qualifier
0 Abdominal Aorta
1 Celiac Artery
2 Gastric Artery
3 Hepatic Artery
4 Splenic Artery
5 Superior Mesenteric Artery
6 Colic Artery, Right
7 Colic Artery, Left
8 Colic Artery, Middle
9 Renal Artery, Right
A Renal Artery, Left
B Inferior Mesenteric Artery
C Common Iliac Artery, Right
D Common Iliac Artery, Left
E Internal Iliac Artery, Right
F Internal Iliac Artery, Left
H External Iliac Artery, Right
0 Open
3 Percutaneous
4 Intraluminal Device, Drug-eluting
D Intraluminal Device
Z No Device
6 Bifurcation
Z No Qualifier
4 Percutaneous
Endoscopic