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?
When autologous graft is obtained from the site of the procedure, (for example, bone graft obtained from the operative site during a fusion procedure) the tissue harvest is typically not coded separately. Therefore, do not assign a separate code for the pericardial excision. The root operation “Supplement” is assigned for the augmentation of the left pulmonary artery and pulmonary trunk as stated in the operative report. Assign ICD-10-PCS codes as follows:
02UR07Z Supplement left pulmonary artery with autologous tissue substitute, open approach
02UP07Z Supplement pulmonary trunk with autologous tissue substitute, open approach