AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2016 Quarter 3; Ask the Editor
Closure of Bilateral Alveolar Clefts
A patient with history of bilateral cleft lip and palate was seen for closure of bilateral patent alveolar clefts. The surrounding scar tissue was mobilized at the left-sided cleft to create a pocket to preserve the bone and place Infuse® bone morphogenetic protein (BMP). On the right side, dermal autograft that was harvested from the left hip was placed into the cleft with Infuse® bone morphogenetic protein. What are the code assignments for bilateral alveolar cleft closure with bilateral placement of bone morphogenetic protein (BMP) and placement of dermal autograft to the right cleft? ...
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Article Overview
This article covers procedure coding for a bilateral alveolar cleft closure case in an inpatient procedure coding context. It is aimed at coders and CDI or coding review staff who need to understand how the case is coded and how the reported procedure details relate to ICD-10-PCS assignment. The discussion is centered on the procedure scenario and the coding framework used for reporting it.
Why This Topic Matters
Bilateral cleft repair cases can involve multiple operative steps and tissue materials, making accurate ICD-10-PCS reporting important for procedure capture and code selection.
What You Will Learn
- How a bilateral alveolar cleft closure case is framed for ICD-10-PCS coding
- How procedure details are organized in relation to coding assignment
- How associated tissue graft and biologic material placement is addressed at a high level
- How the article presents coding for a complex cleft repair scenario
Who Should Read This
- Inpatient coders
- Coding educators
- Clinical documentation integrity specialists
- Revenue cycle staff
Codes Discussed
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