AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2014 Issue 3; Ask the Editor
MAZE Procedure Performed with Coronary Artery Bypass Graft
The patient is a 74-year-old male who had 100% occlusion of the circumflex artery and occlusion of the right coronary artery with tight ostial stenosis of the left anterior descending artery. The patient was placed on cardiopulmonary bypass, and had coronary artery bypass grafting of the left internal mammary to the left anterior descending artery; greater saphenous vein graft to the diagonal branch; saphenous vein graft to the posterior descending artery; and modified left atrial MAZE procedure using AtriCure® radiofrequency ablation with left atrial appendage exclusion using an AtriClip® device. The vein graft was harvested from the right and left greater saphenous vein via a percutaneous endoscopic approach. How is the surgery coded? ...
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Article Overview
This premium article reviews a complex cardiovascular operative report and the associated procedure coding considerations for multiple services performed during the same surgery. It is aimed at coders, auditors, and clinical documentation specialists who work with inpatient cardiovascular procedures and need to understand how the operative details map to ICD-10-PCS reporting.
Why This Topic Matters
Combined cardiac operations often involve several separately reportable procedures, distinct approaches, and multiple anatomic sites. Accurate understanding of the operative record is important for consistent inpatient coding and complete procedure capture.
What You Will Learn
- How a combined cardiac operative report is analyzed for procedure coding
- How multiple procedures performed in one surgery are identified for reporting
- How bypass grafting, maze-related treatment, and vein harvest details are reflected in procedure documentation
- How appendage exclusion is considered within the broader operative context
Who Should Read This
- Inpatient coders
- Cardiology and cardiothoracic coding staff
- Clinical documentation specialists
- Coding auditors
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