AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2016 Issue 2; Ask the Editor
Repair of Tetralogy of Fallot with Autologous Pericardial Patch Graft
A patient with tetralogy of Fallot presents for repair. During the procedure, the anterior portion of the pericardium was resected and treated in glutaraldehyde. Following the repair, the pulmonary arteriotomy site was closed with the autologous pericardial patch to enlarge the main pulmonary artery and left pulmonary artery. The infundibulotomy was closed with an autologous pericardial patch to enlarge the area with running Prolene® suture. Should the pericardial excision be coded separately? Also, should the closure with pericardial patch be coded separately? If so, what is the appropriate root operation? ...
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Article Overview
This article addresses coding questions arising from a tetralogy of Fallot repair that uses autologous pericardial tissue during the operation. It explains the general handling of tissue obtained from the operative site and discusses the procedural classification of the repair in ICD-10-PCS terms. The article is relevant to inpatient procedural coding, congenital heart surgery, and coders reviewing operative reports for cardiac repair cases.
Why This Topic Matters
Cardiac repair cases often involve multiple operative steps that can be difficult to separate for coding purposes. This article helps coders, CDI staff, and auditors understand how a complex congenital heart repair is framed in procedural coding review.
What You Will Learn
- How this cardiac repair scenario is discussed from a coding perspective
- How operative tissue harvest is addressed in relation to separate coding
- How the repair is categorized at a high level within inpatient procedural coding
- What types of questions arise when reviewing patch-based congenital heart surgery documentation
Who Should Read This
- Inpatient coders
- Coding auditors
- Clinical documentation integrity specialists
- Cardiothoracic surgery coding staff
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