A quarterly publication of the

Central Office on ICD-10-CM/PCS

Volume 9 Fourth Quarter
Number 4 2022
In This Issue Intracranial Injury with Unknown
Changes to ICD-10-CM Official Loss of Consciousness 42
Guidelines for Coding and Isthmocele 36
Reporting 79 Limb-Girdle Muscular Dystrophies 17
Changes to ICD-10-PCS Official Lumbar and Lumbosacral
Guidelines for Coding and Intervertebral Annulus
Reporting 88 Fibrosus Disc Defects 28
Malignant Pericardial Effusion 22
New/Revised ICD-10-CM Codes Maternal Care for (Suspected)
Activated Phosphoinositide Fetal A
nomalies 37
3-Kinase Delta Syndrome 11 Mild Neurocognitive Disorder Due to
Acute and Chronic Metabolic Known Physiological Condition 16
Acidosis 13 Mitral Annulus Calcification 23
Antineutrophilic Cytoplasmic Muscle Wasting and Atrophy of Back 29
Antibody Vasculitis 26 Poisoning by, Adverse Effect of,
Aortic Aneurysm and Dissection 24 and Underdosing of
Apnea of Newborn 38 Methamphetamines 45
Candidiasis of Vulva and Vagina 4 Postural Orthostatic Tachycardia
Congenital Atrial Septal Defect, Syndrome 19
Atrioventricular Septal Defect Postviral and Related Fatigue
and P atent Foramen Ovale 39 Syndromes 20
Contrast-Induced Nephropathy 33 Prolonged Grief Disorder 17
Dementia: Stage of Severity, PTEN Hamartoma Tumor
Behavioral and Physical Syndrome, Cowden
Symptoms 14 Syndrome and von
Endometriosis 34 Hippel-Lindau Syndrome 40
Exposure to Inanimate Mechanical Refractory Angina Pectoris 20
Forces Caught, Crushed, Rib Fracture due to Chest
Jammed, or Pinched in or Compression and
Between Objects 48 Cardiopulmonary Resuscitation 31
External Cause of Injury Codes for Short Stature 11
Electric Assisted Bicycles 47 Slipped Upper Femoral Epiphysis
Fournier Disease of Vagina and Vulva 34 (Nontraumatic) 30
Hemolytic-Uremic Syndrome 5 Substance Use of Unspecified
Heparin-Induced Thrombocytopenia 9 Severity in Remission 16
Hepatic Encephalopathy 27 Transfusion-Associated Dyspnea 27

Coding advice and new code assignments contained in this issue

effective with discharges October 1, 2022
Ventricular Tachycardia 23 Extracorporeal Antimicrobial
Von Willebrand Disease 7 Administration During Renal
Replacement Therapy 78
Z Code Update Extracorporeal Histotripsy of
Counseling 51 Targeted Liver Tissue Using
Ultrasound-Guided Cavitation 67
History of Z Codes 50
Gene Expression Assay 78
Observation 51 Implantation of Paired Vagus Nerve
Social Determinants of Health 52 Stimulator Using an External
Status of Z Codes 49 Controller 64
Implantation of Sphenopalatine
New/Revised ICD-10-PCS Codes Ganglion Stimulator for
Section 0 – Medical and Surgical Ischemic Stroke 63
Bladder Augmentation 56 Insertion of a Posterior Spinal
Drainage of Parapharyngeal Space Motion Preservation Device 70
and Retropharyngeal Space 59 Internal Fixation Device with Tulip
Embolization of Prostatic Artery 55 Connector 69
Ileal Ureter 58 Introduction of New Therapeutic
Infusion Device in Head and Substances 71
Facial B
ones 58 Afamitresgene Autoleucel
Laser Interstitial Thermal Therapy 53 Immunotherapy 73
Rapid Deployment Technique for Broad Consortium Microbiota-
Replacement of Aortic Valve Based Live Biotherapeutic
Using Zooplastic Tissue 54 Suspension 74
Ultrasonic Surgical Aspiration Daratumumab and
of Brain 54 Hyaluronidase-Fihj 72
Engineered Allogeneic Thymus
Section 3 – Administration Tissue 74
Introduction of Bone-Substitute Inebilizumab-Cdon 74
Material 61 Maribavir Anti-infective 72
Introduction of Other Therapeutic Mosunetuzumab Antineoplastic 72
Monoclonal Antibody 60 Spesolimab Monoclonal
Antibody 71
Section 5 – Extracorporeal or Tabelecleucel Immunotherapy 73
Systemic Assistance and Teclistamab Antineoplastic 72
Performance Treosulfan 74
Cardiac Perfusion with Intra-Arterial Posterior Vertebral Body Tethering 67
Supersaturated Oxygen 61 Pressure-Controlled Intermittent
Coronary Sinus Occlusion 66
Section B – Imaging Quantitative Flow Rate for
Hyperpolarized Xenon-129 Gas Noninvasive Analysis of
for Imaging of Lung Function 62 Coronary Angiography 77
Replacement of Synthetic
Section D – Radiation Therapy Substitute Meniscus of Knee 70
Deletion of Qualifier Value for Laser Simulation for Assessment of
Interstitial Thermal Therapy 62 Coronary Obstruction Risk 77
Transfusion of New Therapeutic
Section X - New Technology Substances 75
Computer-Aided Analysis for Betibeglogene Autotemcel 75
Detection and Classification Omidubicel 75
of Epileptic Events 76 OTL-103 76
Computer-Assisted Transcranial OTL-200 76
Magnetic Stimulation of
Prefrontal Cortex 65

2 Fourth Quarter 2022 Coding Clinic

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Coding Clinic Fourth Quarter 2022 3
 ICD-10-CM NEW/REVISED CODES
A summary of the Fiscal Year 2023 (FY 2023) ICD-10-CM changes
effective October 1, 2022 are provided below. Addenda changes
demonstrating the specific revisions to the code titles or instructional
notes are not included in the explanations below. The official ICD-10-
CM addenda has been posted on the Centers for Disease Control
and Prevention (CDC) National Center for Health Statistics (NCHS)
website at: https://www.cdc.gov/nchs/icd/Comprehensive-Listing-of-
ICD-10-CM-Files.htm

In response to the national emergency that was declared concerning

the COVID-19 outbreak, the Centers for Disease Control and
Prevention’s (CDC) National Center for Health Statistics (NCHS)
implemented three new ICD-10-CM diagnosis codes: codes Z28.310
and Z28.311, for reporting COVID-19 vaccination status, and Z28.39
for other underimmunization status, effective April 1, 2022. The
information below regarding new or revised ICD-10-CM codes relates
only to codes effective October 1, 2022.

There are 1176 new ICD-10-CM codes effective October 1, 2022.

In addition, there are 28 revised codes and 287 codes have been
deleted (most of these from expansion relegating them to be
subcategories).

Candidiasis of Vulva and Vagina

A new subcategory was created with two new codes to uniquely

identify acute and chronic candidiasis of vulva and vagina as follows:

• B37.31, Acute candidiasis of vulva and vagina

• B37.32, Chronic candidiasis of vulva and vagina

4 Fourth Quarter 2022 Coding Clinic

Candidiasis of vulva and vagina (vulvovaginal candidiasis (VVC)),
commonly known as vaginal yeast infection, is inflammation of the
vulva and vagina due to Candida, typically C albicans. A patient
may experience signs and symptoms that include pruritus, vaginal
soreness, dyspareunia, external dysuria, vulvar edema and erythema,
and abnormal vaginal discharge. Approximately 75% of women will
have at least one episode of VVC in their lifetime. Most cases are
uncomplicated with mild to moderate symptoms and are diagnosed
based on symptoms alone. Typically, these mild or uncomplicated
cases are successfully treated via over-the-counter topical antifungal
creams and/or a short course of oral fluconazole, an antifungal drug.

A small group of women may develop a more complicated form of

VVC. Most often, this refers to recurrent vulvovaginal candidiasis
(RVVC), which is defined as 3 to 4 or more episodes of symptomatic
infection within one year. RVVC is considered chronic candidiasis,
occurring in approximately 5% to 9% of women. These women
typically endure multiple relapses and months of treatment with a
significant impact on their lives. Treatment consists of topical or oral
fluconazole for 10 to 14 days, followed by a maintenance regimen
of oral fluconazole once a week for at least six months. About 50%
of women will have another episode of VVC within three to four
months (a higher percentage over time), when treatment is stopped.
Complicated VVC refers to severe yeast infection, infection in an
immune-compromised woman, or an infection with a non-C albicans
species.

Hemolytic-Uremic Syndrome
Code D59.3, Hemolytic-uremic syndrome, was expanded and new
codes created to identify hemolytic-uremic syndrome, unspecified
(D59.30), infection-associated hemolytic-uremic syndrome (D59.31),
hereditary hemolytic-uremic syndrome (D59.32), and other hemolytic-
uremic syndrome (D59.39).

Hemolytic-uremic syndrome (HUS) is a rare but serious disease

that affects the kidneys and blood clotting mechanisms of affected
people. Typical HUS is the most common form, and occurs secondary
to shiga toxin (Stx) producing bacteria, typically following an
Escherichia coli 0157:H7 gastrointestinal (GI) infection. Anyone who
has been infected with an E. coli O157:H7 strain can develop HUS;
however, only a small percentage will actually develop the condition.

Coding Clinic Fourth Quarter 2022 5

Typical HUS has also been linked to other GI infections, including
shigella and salmonella, as well as non-GI infections, particularly
pneumococcus. Assign code D59.31, Infection-associated hemolytic-
uremic syndrome, for typical HUS.

The syndrome is more common in children under five, but those with
a weakened immune system or a family history of HUS are at an
increased risk of developing the syndrome. Symptoms of HUS include
vomiting, bloody diarrhea, stomach pain, fever, chills and headache.

Some cases of HUS may also be considered atypical (aHUS), as

certain genetic disorders may lead to aHUS. However, in most cases,
there needs to be a triggering event, such as an acute infection
(e.g., COVID-19, chicken pox or influenza). Pregnancy, autoimmune
conditions, transplants, and metabolic conditions are all potential
triggers. Atypical HUS with an identified genetic cause is assigned
code D59.32, Hereditary hemolytic-uremic syndrome. Other forms of
atypical or non-genetic HUS (or without specification of the underlying
cause) is assigned code D59.39, Other hemolytic-uremic syndrome.

Question:
A patient was admitted with hypertension and
chronic kidney disease, stage 3, and atypical
HUS. What is the correct code for atypical
hemolytic-uremic syndrome?

Answer:
Assign code D59.39, Other hemolytic-uremic
syndrome, for atypical hemolytic-uremic
syndrome. Assign codes I12.9, Hypertensive
chronic kidney disease with stage 1 through
stage 4 chronic kidney disease, or unspecified
chronic kidney disease, and N18.3, Chronic
kidney disease, stage 3 (moderate), as
additional diagnoses.

6 Fourth Quarter 2022 Coding Clinic

 Von Willebrand Disease

Code D68.0, Von Willebrand disease, was expanded and new codes
created to specifically identify Von Willebrand disease (VWD) by type.
VWD has been classified into six categories or subtypes, based on
the differences in clinical features and therapeutic requirements as
follows:

• D68.00, Von Willebrand disease, unspecified

• D68.01, Von Willebrand disease, type 1
• D68.020, Von Willebrand disease, type 2A
• D68.021, Von Willebrand disease, type 2B
• D68.022, Von Willebrand disease, type 2M
• D68.023, Von Willebrand disease, type 2N
• D68.029, Von Willebrand disease, type 2, unspecified
• D68.03, Von Willebrand disease, type 3
• D68.04, Acquired Von Willebrand disease
• D68.09, Other Von Willebrand disease

Von Willebrand disease (VWD) is the most common inherited bleeding

disorder in which the blood does not clot properly, making a person
bleed more easily than normal. People with VWD have a low level of a
substance called von Willebrand factor (VWF), a protein in their blood
that helps blood clot, or with some types of VWD, the protein does not
perform, as it should. There are three major types of VWD: Type 1,
Type 2 and Type 3.

Type 1 VWD is characterized by decreased levels of VWF. The VWF

that is produced functions normally; however, the lower circulating
levels lead to an increased risk of bleeding. This is the most common
and mildest form of VWD.

About 15% of people with VWD have type 2. Usually, there are more
severe bleeding problems with this type than in people with type 1.
With type 2 VWD there is enough VWF but it does not work properly.
There is a functional defect in the VWF, which is subtyped based on
the specific functional defect. Type 2 VWD has four subtypes: A, B, M
and N.

Coding Clinic Fourth Quarter 2022 7

 • In type 2A, the VWF is not the correct size. This stops the
platelets from attaching together to make a good platelet plug.
• In type 2B, the VWF is not the correct size and the VWF
becomes too active. It attaches to the platelets in the blood
when it is not supposed to (when there is no injury). The body
quickly removes the platelets with the attached VWF, which
causes a shortage of both platelets and VWF in the blood.
• In type 2M, the VWF is not able to attach to the platelets and a
good platelet plug does not form when an injury occurs.
• In type 2N, the VWF attaches to the platelets normally;
however, it does not attach to factor VIII, as it should. The level
of factor VIII in the body is low because it does not have the
VWF to keep it from being broken down. With low levels of
factor VIII, the body has trouble making a fibrin clot.

Type 3 is the most severe form of VWD. People with this type have
little or no VWF in their blood, and low levels of factor VIII. Because
the symptoms are so severe, type 3 VWD is diagnosed, when the
person is very young, although due to the low factor VIII, the condition
can be misdiagnosed as hemophilia A.

Most people with VWD are born with it, having inherited it from one
or both parents. Often, they are not aware that they have the disease
because the signs are mild or absent and may not show up for years.
The most common sign of the condition is abnormal bleeding. VWD
occurs among men and women equally; however, women are more
likely to notice the symptoms because of heavy or abnormal bleeding
during their menstrual periods and after childbirth.

VWD cannot be cured. With treatment and self-care, most people

with the disease can lead active lives. Rarely, VWD can develop later
in life in people who did not inherit an affected gene from a parent.
This is known as acquired VWD and is likely caused by an underlying
medical condition.

Complications of VWD include uncontrollable bleeding, which can be

life threatening, anemia, swelling and pain in the joints or soft tissue.

8 Fourth Quarter 2022 Coding Clinic

 Question:
The provider documented the patient has both
Von Willebrand disease (VWD), type 1, and
Factor VIII (functional) deficiency. ICD-10-
CM classifies VWD, type 1, to code D68.01,
Von Willebrand disease, type 1, and Factor
VIII deficiency to code D66, Heredity factor
VIII deficiency. Codes D66 and D68.01 are
mutually exclusive based on the Excludes1
notes located at both codes. What codes are
assigned when both VWD type 1 and Factor
VIII deficiency are documented?

Answer:
Assign code D68.01, Von Willebrand disease,
type 1, for VWD with Factor VIII deficiency.
Patients with this type of VWD have a deficiency
of Von Willebrand factor (VWF) and may have
low levels of Factor VIII. Factor VIII deficiency
that occurs as a part of the VWD is not a
separate condition and is not coded separately.

Heparin-Induced Thrombocytopenia

Code D75.82, Heparin induced thrombocytopenia (HIT) was

expanded and new codes were created to identify the different types
of HIT as follows:

• D75.821, Non-immune heparin-induced thrombocytopenia

• D75.822, Immune-mediated heparin-induced
thrombocytopenia
• D75.828, Other heparin-induced thrombocytopenia
syndrome
• D75.829, Heparin-induced thrombocytopenia, unspecified

Code D75.84, Other platelet-activating anti-PF4 disorders, was

also created to classify conditions such as spontaneous heparin-
induced thrombocytopenia syndrome (without heparin exposure),
thrombosis with thrombocytopenia syndrome, and vaccine-induced
thrombotic thrombocytopenia.

Coding Clinic Fourth Quarter 2022 9

HIT is a decrease in platelet count that occurs during or shortly after
exposure to heparin, which is used to prevent or treat blood clots. HIT
is usually an adverse effect of heparin therapy that is often confusing
because in HIT, heparin does the opposite of what it is supposed to
do: it forms rather than prevents new blood clots. Heparin is widely
used so HIT is a common problem and is heparin’s most clinically
relevant non-hemorrhagic adverse effect. It can be serious and life
threatening. In certain cases, the symptoms of HIT can be triggered
by something other than heparin, and so not all cases are directly an
adverse effect of heparin.

HIT may develop in two distinct forms: type I and type II. Type I, also
known as non-immune heparin-induced thrombocytopenia, is a non-
immunologic response to heparin treatment. This type affects 10% of
patients, within the first 48 to 72 hours after initiation of heparin, and is
characterized by a mild and transient thrombocytopenia, which usually
returns to normal within 4 days of heparin being withdrawn. It is not
associated with an increased risk of thrombosis or any significant
complication.

Type II is an immune-mediated response that is associated with a

risk of thrombosis. This type causes thrombocytopenia starting 4-10
days after initiation of heparin treatment and may be associated
with a hypercoagulable state in addition to life and limb-threatening
thrombotic complications (e.g., deep vein thrombosis, pulmonary
embolism, heart attack or stroke).

Other adverse effects of HIT besides thrombocytopenia include

necrotizing skin lesions at the injection site, and acute systemic
reactions (fever, chills, hypertension, tachycardia, etc.).

Autoimmune HIT (aHIT) is a variant of HIT that behaves differently

from the classic form. These patients have atypical presentations
and may have factors that cause their platelet count to continue to
decrease even after heparin is stopped. They present with severe
thrombocytopenia, which might persist for weeks to months despite
discontinuing heparin.

10 Fourth Quarter 2022 Coding Clinic

 Activated Phosphoinositide 3-Kinase
Delta Syndrome [APDS]

A new code was created to identify activated phosphoinositide

3-kinase delta syndrome (D81.82).

APDS (PI3K delta syndrome) is a rare primary immune regulatory

disorder (PIRD) caused by genetic variants in either one of two
identified genes known as PIK3CD or PIK3R1. It is a combined
immunodeficiency and impairs the immune system such that
individuals with this condition typically have low numbers of white
blood cells, particularly certain types of B cells and T cells.

APDS usually manifests during early childhood. The most common

symptoms are frequent and severe infections of the ears, sinuses,
herpes virus infections, neurodevelopment delay, and upper and
lower respiratory tract infections. People with APDS are susceptible
to swollen lymph nodes, an enlarged spleen, autoimmunity and
inflammatory symptoms and are at a higher risk for cancers like
lymphoma. Symptoms vary, even within families carrying the same
mutation. This has led to different APDS treatments across patients.

Short Stature

A new subcategory E34.3, Short stature due to endocrine disorder,

was created with new codes to identify short stature as follows:

• E34.30, Short stature due to endocrine disorder,

unspecified
• E34.31, Constitutional short stature
• E34.321, Primary insulin-like growth factor-1 (IGF-1)
deficiency
• E34.322, Insulin-like growth factor-1 (IGF-1) resistance
• E34.328, Other genetic causes of short stature
• E34.329, Unspecified genetic causes of short stature
• E34.39, Other short stature due to endocrine disorder

Short stature develops with low concentrations of growth hormone

(GH) and insulin-like growth factor-I (IGF-1). It is defined by a height/
length that is two standard deviation scores (SDS) away from the
mean height/length of the age group. Approximately 2.5% of children

Coding Clinic Fourth Quarter 2022 11

are affected by short stature and of those, about 5% or 1 in 1,000
children have short stature due to endocrine disorders.

Children with low levels of GH are said to have GH deficiency (GHD).

Its prevalence is estimated to be between 1:4,000 and 1:10,000.
GHD leads to low levels of IGF-1, a hormone made primarily in the
liver. IGF-1 regulates the growth-promoting effects of GH by acting
on “target” body tissues such as the growth plates of the bones.
GHD is treated with recombinant human GH (rhGH), also known as
somatotropin.

There are several causes of short stature. To evaluate whether growth

impairment leading to short stature is due to an endocrine disorder,
other causes of growth failure will need to be ruled out, including
genetic syndromes such as Turner syndrome and several other
secondary causes like malnutrition and inflammatory disorders.

Constitutional short stature, along with familial (genetic) short stature,

is a form of normal variant short stature often classified as idiopathic
short stature (ISS)—describing patients with an unknown cause of
short stature, or short stature that is the result of a growth pattern
inherited from a parent. Constitutional short stature is also called
constitutional growth delay and is the most common cause of short
stature and pubertal delay. This diagnosis depends on ruling out other
causes of short stature, as well as ruling out GHD. About 70% of
children with short stature have some type of idiopathic short stature,
including constitutional short stature, but also with other unknown
etiologies.

Primary IGF-1 deficiency is characterized by normal GH levels in the

presence of short stature and a low IGF-1 level. Primary in this case
means that no secondary cause of low IGF-1 levels (e.g., chronic
medical illness) can be identified. With this type, the child may suffer
from tiredness and a lack of energy. These children may appear
younger than their peers, but there is no impact on their intellectual
abilities. It occurs in approximately 1 in 300 births in the United States.

IGF-1 deficiency may also be severe and is known as severe primary

IGF-1 deficiency (SPIGFD). IGF-1 deficiency is considered severe
when the IGF-1 levels are extremely low or undetectable in the blood.
The most well recognized form of SPIGFD is a genetic condition
called Laron syndrome. Children with SPIGFD may be successfully
treated with the recombinant human IGF-1 mecasermin.

12 Fourth Quarter 2022 Coding Clinic

IGF-1 resistance can be the result of GH resistance due to genetic
disorders of the GH receptor. It is characterized by normal or elevated
IGF-1 levels and growth failure. Children with growth delay due to
IGF-1 resistance may have variable intrauterine and postnatal growth
retardation.

Acute and Chronic Metabolic Acidosis

Code E87.2, Acidosis, has been expanded to differentiate between

acute and chronic metabolic acidosis. Four new codes have been
created to identify acute metabolic acidosis, chronic metabolic
acidosis, along with unspecified and other specified types of acidosis:

• E87.20, Acidosis, unspecified

• E87.21, Acute metabolic acidosis
• E87.22, Chronic metabolic acidosis
• E87.29, Other acidosis

Metabolic acidosis occurs when there is an acid-base imbalance in

the blood. There is either too much acid in the body or not enough
acid being removed from the body. Treatment is dependent on the
cause of the acid-base imbalance. Metabolic acidosis may cause
rapid breathing, confusion, weakness, and headache.

Acute metabolic acidosis is typically associated with conditions that

result in hospitalization like severe sepsis or hypoperfusion, which is
a reduction in blood flow that causes a drop in oxygen and a buildup
of lactic acid. Disruptions in glucose metabolism can cause a buildup
of ketones in the blood, which are acidic, and can lead to acute
metabolic acidosis. Treatment is primarily directed at correcting the
underlying etiology (e.g., treatment of sepsis, volume resuscitation,
control of hyperglycemia, etc.).

Chronic metabolic acidosis is most commonly caused by a kidney-

related pathology, such as chronic kidney disease (CKD) and is
associated with an increased risk of CKD progression. As the kidney
function deteriorates, adequate amounts of acid cannot be removed
from the body, leading to adverse effects on the musculoskeletal
system like muscle wasting and bone density loss. Other adverse
effects of chronic metabolic acidosis in CKD include cognitive,
vascular, and functional impairments. Treatment for chronic metabolic
acidosis primarily aims to increase the serum bicarbonate level long
term.

Coding Clinic Fourth Quarter 2022 13

 Question:
A 58-year-old man with stage 4 chronic kidney
disease (CKD) presents to the renal clinic. The
provider noted, “Chronic metabolic acidosis and
progressive decline in kidney function.” The
patient was prescribed oral sodium bicarbonate
and advised to follow-up in two weeks. What
are the appropriate code assignments for this
encounter?

Answer:
Assign code N18.4, Chronic disease, stage
4 (severe), as the first-listed code. Code
E87.22, Chronic metabolic acidosis, should be
assigned, as an additional diagnosis.

Dementia: Stage of Severity, Behavioral

and Physical Symptoms

New subcategories have been created with new codes under

categories F01, Vascular Dementia, F02, Dementia in other diseases
classified elsewhere, and F03, Unspecified Dementia.

Vascular dementia (F01.511-F01.C4)

Dementia in other diseases classified elsewhere (F02.811-F02.C4)
Unspecified dementia (F03.911-F03.C4)

Sixty-nine new codes have been created under these categories to

recognize the stages of severity and to identify the behavioral and
psychological symptoms of dementia (BPSD).

Dementia is a progressive disease, now also regularly referred to

as major neurocognitive disorder. Dementia is characterized by
a significant decline in cognitive function in the areas of memory,
problem solving, attention, and language skills. It is generally due
to an underlying disorder such as cerebrovascular disease or
Alzheimer’s disease, although the specific underlying condition cannot
always be determined.

Progression of dementia moves through three stages of cognitive

impairment: mild dementia, moderate dementia, and severe dementia.
Mild dementia includes patients who are no longer fully independent

14 Fourth Quarter 2022 Coding Clinic

and require occasional daily assistance with activities. Moderate
dementia involves an extensive functional impact on everyday life
with impairment in basic activities. Patients are no longer independent
and require frequent assistance with daily living activities. Severe
dementia indicates a complete dependency due to severe functional
impact on daily life with impairments in basic activities, including basic
self-care.

Additional details have been added to the dementia codes to capture

the BPSD, such as, but not limited to, psychotic disorder, mood
disorders, and anxiety. BPSD can be grouped into three broad
categories: behavioral disturbances, psychotic disorders, and mood
(affective) disorders. The associated disorders such as agitation,
anxiety, and combativeness are the conditions responsible for driving
care in patients with dementia. Dementia itself is not directly treatable;
what is being treated during an encounter or admission are the
BPSDs.

The stages of dementia and BPSD can vary from patient to patient.
Some symptoms, primarily linked to behavior that may develop at
one stage may disappear at a later stage. Other symptoms like
memory loss or problems with thinking and talking tend to stay and
progressively worsen over time. Therefore, it is essential for clinical
data purposes to identify the stages at which these disorders develop
and how they present in patients.

Question:
A patient with known severe dementia due
to late onset of Alzheimer’s disease and
functional quadriplegia is admitted from a
senior living facility due to increased agitation
and combativeness over the past three days.
What is the appropriate code assignment for
severe dementia in a patient with agitation and
combativeness?

Answer:
Assign codes G30.1, Alzheimer’s disease with
late onset, and F02.C11, Dementia in other
diseases classified elsewhere, severe, with
agitation. Code R53.2, Functional quadriplegia,
may be assigned for the quadriplegia.

Coding Clinic Fourth Quarter 2022 15

 Mild Neurocognitive Disorder Due to Known
Physiological Condition

Mild neurocognitive disorder, also known as mild cognitive impairment

(MCI), can be defined as an impairment in memory or thinking that
is beyond what is considered normal age-related changes and yet,
not so severe that it is considered dementia. MCI symptoms are
subtle and do not significantly affect a patient’s daily life and activities.
Patients with MCI typically do not experience other disturbances
such as personality changes or functional impairments but are at an
increased risk for developing dementia caused by Alzheimer’s or other
neurological conditions. Typical symptoms include forgetfulness and
word-finding difficulties.

Subcategory F06.7, Mild neurocognitive disorder due to known

physiological condition, and new codes have been created to identify
mild cognitive disorder due to other physiological conditions.

• F06.70, Mild neurocognitive disorder due to known

physiological condition without behavioral disturbance
• F06.71, Mild neurocognitive disorder due to known
physiological condition with behavioral disturbance

These codes are assigned to capture MCI in patients who have not
yet developed dementia. The fifth-digit classifies the presence or
absence of behavioral disturbances. This will allow for tracking of the
progression of behavioral symptoms that are a significant indicator of
the progression of the underlying disease.

Substance Use of Unspecified Severity in Remission

New diagnosis codes have been created to identify “in remission”

for the following substances, when the previous severity of usage is
unknown (as to whether there was abuse or dependence), and thus
classified as unspecified.

• F10.91, Alcohol use, unspecified, in remission

• F11.91, Opioid use, unspecified, in remission
• F12.91, Cannabis use, unspecified, in remission
• F13.91, Sedative, hypnotic or anxiolytic use, unspecified,
in remission
• F14.91, Cocaine use, unspecified, in remission

16 Fourth Quarter 2022 Coding Clinic

 • F15.91, Other stimulant use, unspecified, in remission
• F16.91, Hallucinogen use, unspecified, in remission
• F18.91, Inhalant use, unspecified, in remission
• F19.91, Other psychoactive substance use, unspecified, in
remission

Code F10.90, Alcohol use, unspecified, uncomplicated, was also

created to capture cases where the alcohol use pattern is unknown,
but it is known that the alcohol use is not complicated and is not
associated with an alcohol-induced disorder, such as alcohol-induced
mood disorder.

Prolonged Grief Disorder

Code F43.8, Other reactions to severe stress, has been expanded,

and two new codes have been created:

• F43.81, Prolonged grief disorder

• F43.89, Other reactions to severe stress

Prolonged grief disorder (PGD) also referred to as complicated grief

and persistent grief disorder, is different from normal grief in that
the immediate grief reactions are described as persistent beyond
twelve months post-loss. Signs include considerable loss of everyday
functioning, persistent longing for the deceased person, difficulty
accepting the death, the feeling of having lost part of oneself, difficulty
continuing with life, emotional numbness, and avoidance of activities
that serve as reminders of the deceased. PGD is most common
among people who have lost a child or romantic partner and is more
likely to occur after sudden or violent deaths.

PGD is distinct from other mental disorders, including major

depressive disorder, general anxiety disorder, and post-traumatic
stress disorder.

Limb-Girdle Muscular Dystrophies

Subcategory G71.0, Muscular dystrophy, has been expanded, and

a new sub-subcategory (G71.03) has been created for limb-girdle
muscular dystrophies (LGMD). New codes were created to uniquely
identify several subtypes of LGMD as listed below:

Coding Clinic Fourth Quarter 2022 17

 • G71.031, Autosomal dominant limb girdle muscular
dystrophy
• G71.032, Autosomal recessive limb girdle muscular
dystrophy due to calpain-3 dysfunction
• G71.033, Limb girdle muscular dystrophy due to dysferlin
dysfunction
• G71.0340, Limb girdle muscular dystrophy due to
sarcoglycan dysfunction, unspecified
• G71.0341, Limb girdle muscular dystrophy due to alpha
sarcoglycan dysfunction
• G71.0342, Limb girdle muscular dystrophy due to beta
sarcoglycan dysfunction
• G71.0349, Limb girdle muscular dystrophy due to other
sarcoglycan dysfunction
• G71.035, Limb girdle muscular dystrophy due to
anoctamin-5 dysfunction
• G71.038, Other limb girdle muscular dystrophy
• G71.039, Limb girdle muscular dystrophy, unspecified

Limb Girdle Muscular Dystrophies is a general term used to describe

a group of rare genetic disorders that cause muscle atrophy and
weakness predominantly around the shoulder girdle and pelvic girdle.
The shoulder and pelvic girdles are bony structures surrounding the
shoulders and hips, respectfully. Collectively, these are called the limb
girdles.

There are currently 34 subtypes of LGMD that have been identified

based upon abnormal mutations of specific genes. The age of
onset, severity, and progression of symptoms of these subtypes vary
significantly from patient to patient. Some patients may have a mild,
slow progression, while others may have a rapidly progressive form
that causes severe disabilities.

LGMD is an uncommon disorder and specific LGMD subtypes are

distinguished by genetic and protein analysis. The various forms of
LGMD may be inherited as autosomal dominant or recessive traits.
Autosomal recessive LGMDs are caused by mutations in genes
that code for proteins such as calpain-3, dysferlin, anoctamin-5,
and alpha-sarcoglycan. Furthermore, sarcoglycan is a tetramer and
is made up of four subunits: alpha-sarcoglycan, beta-sarcoglycan,
gamma-sarcoglycan, and delta-sarcoglycan.

18 Fourth Quarter 2022 Coding Clinic

 Postural Orthostatic Tachycardia Syndrome

Category G90, Disorders of autonomic nervous system, has been

expanded with the creation of code G90.A, Postural orthostatic
tachycardia syndrome [POTS].

Postural orthostatic tachycardia syndrome (POTS), sometimes

referred to as chronic orthostatic tachycardia syndrome and postural
tachycardia syndrome, is a form of orthostatic intolerance (OI). OI is a
reduction in blood volume that returns to the heart after an individual
stands up from a lying down position. The primary symptoms of OI
are lightheadedness and loss of consciousness. In POTS, these
symptoms are accompanied by tachycardia. Patients are typically
relieved of symptoms once they lie back down again.

Typically, gravity pulls blood down when individuals stand from a lying
down position. In response, blood vessels constrict, and the heart
rate increases slightly to maintain blood flow to the heart and prevent
a drop in blood pressure. This process is regulated by the autonomic
nervous system (ANS) and works automatically without conscious
effort. However, patients with POTS experience a drop in blood flow to
the heart upon standing, and the body compensates by increasing the
heart rate, thereby going into tachycardia. Patients with POTS cannot
coordinate the balance of blood flow and heart rate when standing,
so the condition is classified as a form of dysautonomia and not a
circulatory system disorder.

The symptoms of POTS may vary. For some patients, symptoms

come and go. In other cases, symptoms may subside completely if
an underlying cause is found and treated. However, in most cases,
adjustments in diet, medications, and physical activity improve the
quality of life, although residual symptoms are common.

Question:
A patient was admitted with symptoms of
fatigue, palpitations, and breathlessness.
During the diagnostic workup, the patient’s
symptoms were associated with standing
upright. The blood pressure remained stable;
however, the heart rate went up upon standing.
The provider made a diagnosis of POTS. What
is the correct code assignment for POTS? Is
tachycardia coded separately?

Coding Clinic Fourth Quarter 2022 19

 Answer:
Assign code G90.A, Postural orthostatic
tachycardia syndrome [POTS]. No additional
code is assigned for the tachycardia, as it is
inherent to the diagnosis of POTS.

Postviral and Related Fatigue Syndromes

Subcategory G93.3, Postviral fatigue syndrome, has been retitled to
“Postviral and related fatigue syndrome” and new codes created as
follows:

• G93.31, Postviral fatigue syndrome

• G93.32, Myalgic encephalomyelitis/chronic fatigue
syndrome
• G93.39, Other post infection and related fatigue
syndromes

Postviral fatigue syndrome is a condition represented by an extended

period of fatigue that can linger for weeks or months following a viral
infection and is not necessarily related to the severity of the initial viral
infection.

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is

a chronic, multi-system disease affecting millions of people. The
syndrome is complex, debilitating and includes the hallmark symptom
of post-exertional malaise with a wide spectrum of severity, from mild
to very severe. Although the exact cause of ME/CFS is not known, it
often follows an infectious-like illness.

Code G93.39 is assigned for postbacterial fatigue syndrome,

postinfectious fatigue syndrome, and other types of fatigue syndromes
for which a specific code does not exist.

Refractory Angina Pectoris

A unique code has been created for refractory angina pectoris,

as well as new codes identifying refractory angina pectoris with
atherosclerosis of the native coronary artery and of the following
bypass grafts: unspecified, autologous vein and artery, nonautologous
biological, native coronary artery of transplanted heart, and bypass
graft of other coronary artery as follows:

20 Fourth Quarter 2022 Coding Clinic

 • I20.2 Refractory angina pectoris
• I25.112 Atherosclerotic heart disease of native
coronary artery with refractory angina
pectoris
• I25.702 Atherosclerosis of coronary artery bypass
graft(s), unspecified, with refractory angina
pectoris
• I25.712 Atherosclerosis of autologous vein coronary
artery bypass graft(s) with refractory angina
pectoris
• I25.722 Atherosclerosis of autologous artery coronary
artery bypass graft(s) with refractory angina
pectoris
• I25.732 Atherosclerosis of nonautologous biological
coronary artery bypass graft(s) with refractory
angina pectoris
• I25.752 Atherosclerosis of native coronary artery
of transplanted heart with refractory angina
pectoris
• I25.762 Atherosclerosis of bypass graft of coronary
artery of transplanted heart with refractory
angina pectoris
• I25.792 Atherosclerosis of other coronary artery
bypass graft(s) with refractory angina pectoris

Chronic refractory angina pectoris is angina caused by irreversible

ischemia, lasting more than three months, and not controlled by a
combination of medication, percutaneous coronary intervention (PCI),
or coronary artery bypass graft (CABG) surgery. Caring for patients
with refractory angina pectoris is challenging since treatment options
are limited and further revascularization is contraindicated, as these
patients are unsuitable for, or have a higher risk for PCI and CABG
surgery.

These codes will differentiate refractory angina pectoris from other

types of angina and will help to ensure precise coding for data
collection.

Question:
A patient with a history of coronary artery
disease (CAD) status post quadruple coronary
bypass procedure, and multiple coronary
interventions, including angioplasty with

Coding Clinic Fourth Quarter 2022 21

 stent placement presents to the Emergency
Department (ED) with severe chest pain. The
provider documents chronic refractory angina
pectoris and refers the patient to a cardiac
specialist for further management. How would
this encounter be coded?

Answer:
Assign codes I25.702, Atherosclerosis of
coronary artery bypass graft(s), unspecified,
with refractory angina pectoris, as the first-listed
diagnosis. Assign also code Z98.61, Coronary
angioplasty status.

Malignant Pericardial Effusion

Code I31.3, Pericardial effusion (noninflammatory), has been

expanded and two new codes created as follows:

• I31.31, Malignant pericardial effusion in diseases

classified elsewhere
• I31.39, Other pericardial effusion (noninflammatory)

Malignant pericardial effusion is a common and serious complication

of advanced neoplastic disease. Although primary tumors of the
pericardium are rare, metastasis to the heart and pericardium has
been reported in approximately 20% of cancer patients. Patients with
malignant pericardial effusion typically have a very poor prognosis.

The instructional note at code I31.31 provides sequencing direction,

and the underlying neoplasm is sequenced first.

Question:
A patient with lung cancer presented to the
emergency room with complaints of dry cough,
shortness of breath and sharp pleuritic chest
pain, and was admitted Following work-up,
the provider diagnosed malignant pericardial
effusion. Pericardiocentesis was performed with
placement of a drain. What are the appropriate
diagnosis code assignments for this admission?

22 Fourth Quarter 2022 Coding Clinic

 Answer:
Assign code C34.90, Malignant neoplasm of
unspecified part of bronchus or lung, as the
principal diagnosis. Code I31.31, Malignant
pericardial effusion in diseases classified
elsewhere, should be assigned, as a secondary
diagnosis.

Mitral Annulus Calcification

Code I34.8, Other nonrheumatic mitral valve disorders, has been

expanded and new codes created to capture nonrheumatic mitral
valve disorders as follows:

• I34.81, Nonrheumatic mitral (valve) annulus calcification

• I34.89, Other nonrheumatic mitral (valve) disorders

Mitral annulus calcification (MAC) is a chronic degenerative condition

of the fibrous base of the mitral valve. Some contributing factors
for MAC include age, atherosclerosis, chronic kidney disease, and
congenital metabolic disorders. MAC can also be due to increased
mitral valve stress from conditions such as hypertension, aortic
stenosis or hypertrophic cardiomyopathy. There is a higher incidence
of this condition in females.

MAC is often an incidental finding among patients who are being

evaluated for cardiovascular or pulmonary disease. This condition is
associated with an increased risk of cardiovascular disease, mitral
valve disease, and arrhythmias. MAC may also influence the outcome
of cardiac procedures and interventions.

Ventricular Tachycardia

Code I47.2, Ventricular tachycardia, has been expanded with the

creation of three new codes to identify Torsades de pointes and
unspecified and other types of ventricular tachycardia as follows:

• I47.20, Ventricular tachycardia, unspecified

• I47.21, Torsades de pointes
• I47.29, Other ventricular tachycardia

Coding Clinic Fourth Quarter 2022 23

Ventricular tachycardia, also referred to as VT or V-tach, is arrhythmia
that is caused by irregular electrical signals in the ventricles. Torsades
de pointes (TdP), is a type of polymorphic ventricular tachycardia.
It is an uncommon type of tachycardia arrhythmia, in which the
heart’s two lower chambers (ventricles) beat faster than the two
upper chambers (atria). TdP may resolve without therapy; however,
if untreated, ventricular fibrillation could develop and possibly lead to
cardiac arrest. Many patients with TdP are asymptomatic; however,
patients with this condition may experience dizziness, palpitations,
lightheadedness and/or syncope.

TdP is associated with long QT syndrome, which can be an acquired

or congenital condition. TdP can be triggered by certain medications,
such as antipsychotics, antiemetics, or antiarrythmics. It can also be
related to electrolyte abnormalities.

Question:
A patient presented to the emergency
room due to dizziness and palpitations. An
electrocardiogram was performed and the
patient was diagnosed with Torsades de
pointes (TdP) due to an adverse effect of
prescribed antipsychotic medication. What are
the appropriate diagnosis code assignments for
this encounter?

Answer:
Assign code I47.21, Torsades de pointes, as
the principal diagnosis. Assign code T43.505A,
Adverse effect of unspecified antipsychotics
and neuroleptics, initial encounter, as a
secondary diagnosis to capture the adverse
effect of the antipsychotic medication.
Dizziness and palpitations are inherent to TdP
and are not coded separately.

Aortic Aneurysm and Dissection

Codes within category I71, Aortic aneurysm and dissection, have

been expanded to describe the site of thoracic aorta dissection, as
well as the various types of abdominal aortic aneurysms with and
without rupture as follows:

24 Fourth Quarter 2022 Coding Clinic

 • I71.010, Dissection of ascending aorta
• I71.011, Dissection of aortic arch
• I71.012, Dissection of descending thoracic aorta
• I71.019, Dissection of thoracic aorta, unspecified
• I71.10, Thoracic aortic aneurysm, ruptured, unspecified
• I71.11, Aneurysm of the ascending aorta, ruptured
• I71.12, Aneurysm of the aortic arch, ruptured
• I71.13, Aneurysm of the descending thoracic aorta,
ruptured
• I71.20, Thoracic aortic aneurysm, without rupture,
unspecified
• I71.21, Aneurysm of the ascending aorta, without rupture
• I71.22, Aneurysm of the aortic arch, without rupture
• I71.23, Aneurysm of the descending thoracic aorta,
without rupture
• I71.30, Abdominal aortic aneurysm, ruptured, unspecified
• I71.31, Pararenal abdominal aortic aneurysm, ruptured
• I71.32, Juxtarenal abdominal aortic aneurysm, ruptured
• I71.33, Infrarenal abdominal aortic aneurysm, ruptured
• I71.40, Abdominal aortic aneurysm, without rupture,
unspecified
• I71.41, Pararenal abdominal aortic aneurysm, without
rupture
• I71.42, Juxtarenal abdominal aortic aneurysm, without
rupture
• I71.43, Infrarenal abdominal aortic aneurysm, without
rupture
• I71.50, Thoracoabdominal aortic aneurysm, ruptured,
unspecified
• I71.51, Supraceliac aneurysm of the abdominal aorta,
ruptured
• I71.52, Paravisceral aneurysm of the abdominal aorta,
ruptured
• I71.60, Thoracoabdominal aortic aneurysm, without
rupture, unspecified
• I71.61, Supraceliac aneurysm of the abdominal aorta,
without rupture
• I71.62, Paravisceral aneurysm of the abdominal aorta,
without rupture

Coding Clinic Fourth Quarter 2022 25

A dissection is the abnormal and sometimes abrupt tear of the inside
layer of a blood vessel that allows blood to flow between the layers
that make up the vessel wall, separating these layers. The blood that
accumulates inside this false lumen can cause blood clots or block
blood flow.

An aneurysm is a localized abnormal dilation of a blood vessel.

Aneurysms can also enlarge and rupture. As the aneurysm
progresses, tension may increase and the aneurysm is likely to
rupture, which can result in death. Patients who present with a
dissection or an aneurysm of the aorta are typically treated based on
the site. The new codes describe the location of the dissection and/or
aneurysm, as well as whether the aneurysm has ruptured.

A “dissecting aneurysm” is one in which blood enters the wall of

the artery and separates the layers of the vessel wall, causing the
arterial wall to bulge. “Dissecting aneurysm” implies an acute arterial
dissection. Generally, the dissection is the most significant problem
as the bulging/aneurysm is not present prior to the dissection; it
occurs secondary to the dissection. When a “dissecting aneurysm” is
documented, only the appropriate dissection code is assigned.

Antineutrophilic Cytoplasmic
Antibody [ANCA] Vasculitis

Code I77.82, Antineutrophilic cytoplasmic antibody [ANCA]

vasculitis, has been created to capture the group of autoimmune
diseases that are characterized by inflammation of blood vessels,
affecting multiple body systems.

ANCA are autoantibodies that target and overly activate neutrophils,

a specific type of white blood cell that serves as the immune system’s
first line of defense. There are three main types of ANCA vasculitis:
granulomatosis with polyangiitis (GPA), microscopic polyangiitis
(MPA) and eosinophilic granulomatosis with polyangiitis (EGPA).
Microscopic polyangiitis is the most common type of ANCA. These
systemic conditions are linked together under the umbrella term ANCA
associated vasculitis since they are all associated with “ANCA” and
cause inflammation and/or damage to small blood vessels.

26 Fourth Quarter 2022 Coding Clinic

Although any part of the body can be affected by ANCA associated
vasculitis, the most commonly affected body parts and organs are
the kidneys, lungs, joints, ears, nose and nerves. Early diagnosis
and treatment of ANCA vasculitis is critical to prevent serious organ
damage to vital organs, such as the lungs or kidneys. Although ANCA
vasculitis is a rare condition, it affects thousands of people in the
United States annually.

Other forms of ANCA vasculitis include drug-induced vasculitis

and renal limited vasculitis. Under code I77.82, “ANCA associated
vasculitis” and “ANCA positive vasculitis” have been added as
inclusion terms.

Transfusion-Associated Dyspnea

Code J95.87, Transfusion-associated dyspnea (TAD), has been

created to capture acute respiratory distress that occurs within 24
hours of cessation of transfusion. The code was created because
TAD does not meet the definition of transfusion circulatory overload
(TACO), transfusion-related acute lung injury (TRALI) or allergic
reaction due to a transfusion.

Transfusion related pulmonary events (TAD, TACO and TRALI)

account for 35% of serious reactions and 65% of fatalities of
transfusion related adverse events. TAD can be caused by red
blood cell, platelet or plasma transfusions, and has been reported
as an adverse effect secondary to COVID-19 convalescent plasma
transfusions.

Hepatic Encephalopathy

Subcategory K76.8, Other specified diseases of liver, has been further

expanded, and code K76.82, Hepatic encephalopathy, has been
created to uniquely identify hepatic encephalopathy (without coma).

Hepatic encephalopathy (HE) is a specific type of encephalopathy that

occurs when liver disease causes toxins to build up in the patient’s
blood. Ammonia is one of the toxins that is normally made harmless
by the liver. However, when ammonia or other toxic substances build
up in the body and the liver is unable to remove these toxins from the
blood, these toxins may travel to the brain and temporarily affect brain
function.

Coding Clinic Fourth Quarter 2022 27

Symptoms of HE include anxiety, cognitive impairment, issues with
balance, muscle twitches, impaired thinking, mood changes, sleep
problems and hand flapping. There are treatments such as antibiotics
that stop bacterial growth and medications that reduce ammonia
and remove toxins from the body and into the colon. However, if
the underlying cause of the liver disease is not treated and toxins
continue to build, patients with advanced HE lose consciousness and
go into a hepatic coma.

This new code will allow hepatic encephalopathy (without coma) to be

accurately classified, and will enable enhanced reporting/tracking for
research and clinical purposes.

Lumbar and Lumbosacral Intervertebral

Annulus Fibrosus Disc Defects

A new subcategory M51.A, Other lumbar and lumbosacral annulus

fibrosus disc defects, has been created with new codes to identify
both small and large annular defects in patients with lumbar or
lumbosacral disc herniation who have undergone discectomy surgery.
The new codes are as follows:

• M51.A0, Intervertebral annulus fibrosus defect, lumbar

region, unspecified size
• M51.A1, Intervertebral annulus fibrosus defect, small,
lumbar region
• M51.A2, Intervertebral annulus fibrosus defect, large,
lumbar region
• M51.A3, Intervertebral annulus fibrosus defect,
lumbosacral region, unspecified size
• M51.A4, Intervertebral annulus fibrosus defect, small,
lumbosacral region
• M51.A5, Intervertebral annulus fibrosus defect, large,
lumbosacral region

An intervertebral disc consists of two parts, the annulus fibrosus and

nucleus pulposus. The annulus fibrosis is the sturdy tire-like outer
portion of the disc, while the nucleus pulposus is the softer gel-like
inner cartilage.

A lumbar discectomy is the preferred surgical method for treating

debilitating chronic pain caused by lumbar disc herniation. During

28 Fourth Quarter 2022 Coding Clinic

surgery, the affected vertebrae and disc are exposed, and the
herniated disc is removed. In some instances, the annulus fibrosus
is ruptured during the herniation. If a large annular defect occurs, the
remaining nucleus pulposus in the intervertebral space may herniate
through the annular defect causing symptoms to recur. Symptomatic
lumbar disc herniation, following a lumbar discectomy, is associated
with poor clinical outcomes and often requires surgery. The risk of
symptom recurrence is higher in patients with large versus small
annular defects.

The new codes will allow researchers and clinicians to track and
further assess patient outcomes following lumbar/lumbosacral
discectomy.

Muscle Wasting and Atrophy of the Back

A new subcategory M62.5A, Muscle wasting and atrophy, not

elsewhere classified, back, has been created with new codes to
separately identify muscle wasting and atrophy of the cervical,
thoracic, lumbosacral and unspecified level of the back as follows:

• M62.5A0, Muscle wasting and atrophy, not elsewhere

classified, back, cervical
• M62.5A1, Muscle wasting and atrophy, not elsewhere
classified, back, thoracic
• M62.5A2, Muscle wasting and atrophy, not elsewhere
classified, back, lumbosacral
• M62.5A9, Muscle wasting and atrophy, not elsewhere
classified, back, unspecified level

Two of the main muscle groups of the back that experience muscle
wasting and atrophy are the multifidus muscle and the paraspinal
muscles. Muscle atrophy is the thinning or wasting of muscle mass,
which can be due to malnutrition, age, genetics, a lack of physical
activity or certain medical conditions. Symptoms include muscle
weakness and decreased muscle tone, trouble walking or balancing,
delayed gross motor skills, numbness or tingling in the arms and legs,
limited mobility, scoliosis, and an increase in fat deposits within the
muscles. A fatty infiltration of the lumbar multifidus is common among
adults and is associated with low back pain.

Coding Clinic Fourth Quarter 2022 29

 Slipped Upper Femoral Epiphysis (Nontraumatic)

Subcategory M93.0, Slipped upper femoral epiphysis (nontraumatic),

has been further expanded and new codes have been created to
specifically identify unspecified, acute, chronic, and acute on chronic
slips of the hip. This expansion also includes new subcategories to
describe the stability of the hip as stable, unstable and unspecified
stability. The new codes are as follows:

• M93.004, Unspecified slipped upper femoral epiphysis

(nontraumatic), bilateral hips
• M93.014, Acute slipped upper femoral epiphysis, stable
(nontraumatic), bilateral hips
• M93.024, Chronic slipped upper femoral epiphysis, stable
(nontraumatic), bilateral hips
• M93.034, Acute on chronic slipped upper femoral
epiphysis, stable (nontraumatic), bilateral hips
• M93.041, Acute slipped upper femoral epiphysis, unstable
(nontraumatic), right hip
• M93.042, Acute slipped upper femoral epiphysis, unstable
(nontraumatic), left hip
• M93.043, Acute slipped upper femoral epiphysis, unstable
(nontraumatic), unspecified hip
• M93.044, Acute slipped upper femoral epiphysis, unstable
(nontraumatic), bilateral hips
• M93.051, Acute on chronic slipped upper femoral
epiphysis, unstable (nontraumatic), right hip
• M93.052, Acute on chronic slipped upper femoral
epiphysis, unstable (nontraumatic), left hip
• M93.053, Acute on chronic slipped upper femoral
epiphysis, unstable (nontraumatic), unspecified hip
• M93.054, Acute on chronic slipped upper femoral
epiphysis, unstable (nontraumatic), bilateral hips
• M93.061, Acute slipped upper femoral epiphysis,
unspecified stability (nontraumatic), right hip
• M93.062, Acute slipped upper femoral epiphysis,
unspecified stability (nontraumatic), left hip
• M93.063, Acute slipped upper femoral epiphysis,
unspecified stability (nontraumatic), unspecified hip
• M93.064, Acute slipped upper femoral epiphysis,
unspecified stability (nontraumatic), bilateral hips

30 Fourth Quarter 2022 Coding Clinic

 • M93.071, Acute on chronic slipped upper femoral
epiphysis, unspecified stability (nontraumatic), right hip
• M93.072, Acute on chronic slipped upper femoral
epiphysis, unspecified stability (nontraumatic), left hip
• M93.073, Acute on chronic slipped upper femoral
epiphysis, unspecified stability (nontraumatic),
unspecified hip
• M93.074, Acute on chronic slipped upper femoral
epiphysis, unspecified stability (nontraumatic), bilateral
hips

A slipped upper femoral epiphysis (SUFE), also known as a

slipped capital femoral epiphysis (SCFE), is a condition in which a
damaged growth plate causes slippage of the overlying end of the
proximal femur. Typically, adolescents are diagnosed with SUFE,
and the condition develops gradually. The exact cause of SUFE is
unknown; however, obesity (a major risk factor), hypothyroidism and
osteodystrophy are associated with the condition.

SUFE may present as stable or unstable. A stable SUFE can cause

pain, stiffness, and instability in the hip or groin area, which can lead
to a limp that occurs from time to time over weeks or months and
becomes worse with moderate to intense physical activity. In a stable
SUFE, the adolescent is able to bear weight on the affected hip, with
or without an assistive device. A stable SUFE is usually treated with
corrective surgery using screws and pins through the growth plate
until skeletal growth is complete. An unstable SUFE is typically more
severe where the adolescent is not able to bear any weight on the
affected hip, even with the aid of an assistive device. An unstable
SUFE can occur suddenly and is more painful to the hip and groin
area. It can lead to complications that are more serious. Surgery is
typically extensive with a longer recovery time.

Rib Fracture due to Chest Compression and

Cardiopulmonary Resuscitation

A new subcategory M96.A, Fracture of ribs, sternum and thorax

associated with compression of the chest and cardiopulmonary
resuscitation has been created with new codes to specifically
identify thoracic fractures due to performance of cardiopulmonary
resuscitation (CPR) and chest compressions as follows:

Coding Clinic Fourth Quarter 2022 31

 • M96.A1, Fracture of sternum associated with chest
compression and cardiopulmonary resuscitation
• M96.A2, Fracture of one rib associated with chest
compression and cardiopulmonary resuscitation
• M96.A3, Multiple fractures of ribs associated with chest
compression and cardiopulmonary resuscitation
• M96.A4, Flail chest associated with chest compression
and cardiopulmonary resuscitation
• M96.A9, Other fracture associated with chest
compression and cardiopulmonary resuscitation

Fractures of the rib are a known risk and a common occurrence,

following closed chest compression. Elderly patients and persons
with pre-existing medical conditions, such as osteoporosis, have
an increased risk for this type of injury. Reports indicate that the
incidence of rib fractures in adults due to the performance of
conventional CPR ranges from 13% to 97%, and of sternal fractures
from 1% to 43%. When providing external chest pressure to support
perfusion to the brain or other vital organs, rib fractures may be an
unavoidable occurrence.

The creation of the new codes will aid in the reporting/tracking of

fractures associated with chest compressions and CPR for research
and clinical purposes.

Question
An 89-year-old female patient, who was
admitted to the hospital for cardiac workup,
became hypotensive and unresponsive
following a cardiac catheterization. The
patient’s pulse was nonpalpable and
cardiopulmonary resuscitation (CPR) was
initiated. The patient suffered multiple
fractured ribs due to the chest compressions
and palliative care was consulted for pain
management options. What are the diagnosis
code assignments for the rib fractures due to
CPR?

Answer:
Assign code M96.A3, Multiple fractures of
ribs associated with chest compression and

32 Fourth Quarter 2022 Coding Clinic

 cardiopulmonary resuscitation, for the rib
fractures due to CPR. An external cause code
from Chapter 20 is not assigned because the
external cause and intent are included in code
M96.A3.

Contrast-Induced Nephropathy
Code N14.1, Nephropathy induced by other drugs, medicaments
and biological substances, has been expanded and new codes were
created as follows:

• N14.11, Contrast-induced nephropathy

• N14.19, Nephropathy induced by other drugs,
medicaments and biological substances

Contrast-induced nephropathy (CIN) is a rare but extremely serious

kidney disorder associated with contrast dyes used in tests such as
computerized tomography (CT) and angiograms. CIN is the third
leading cause of hospital acquired acute kidney injury (AKI). The
risk for CIN can increase for people with a history of heart disease,
diabetes, and chronic kidney disease (CKD).

The new codes will aid in the reporting/tracking of contrast-induced

nephropathy for research and clinical purposes.

Question:
A 60-year-old female was diagnosed with
acute kidney injury (AKI) due to acute
tubular necrosis (ATN) secondary to contrast
nephropathy. What is the appropriate code
assignment for acute kidney injury due to
acute tubular necrosis secondary to contrast
nephropathy?

Answer:
Assign codes N17.0, Acute kidney failure
with tubular necrosis, N14.11, Contrast-
induced nephropathy, and T50.8X5A, Adverse
effect of diagnostic agents, initial encounter,
for acute kidney injury (AKI) due to acute
tubular necrosis (ATN) secondary to contrast
nephropathy.

Coding Clinic Fourth Quarter 2022 33

 Fournier Disease of Vagina and Vulva

Subcategory N76.8, Other specified inflammation of vagina and

vulva, has been expanded with the creation of code N76.82, Fournier
disease of vagina and vulva.

Fournier’s disease, also known as Fournier’s gangrene, is a bacterial

necrotizing soft tissue infection that affects the genitals and perineum
(i.e., area between the scrotum and anus in men and between the
vulva and anus in women). Fournier’s disease can develop after
a wound or abrasion becomes infected. It is also often a diabetic
complication. The condition usually begins abruptly with severe
pain and may spread rapidly. Early surgical debridement of necrotic
tissues and antibiotics are vital in the treatment of Fournier’s disease.
Mortality rates are high and average between 20-30% despite
advanced management.

The creation of this code will aid in the tracking/reporting of Fournier’s

disease of the vagina and vulva for research and clinical purposes.

Endometriosis

Subcategories N80.0-N80.5, for endometriosis of uterus (N80.0-),

ovary (N80.1-), fallopian tube (N80.2-), pelvic peritoneum (N80.3-),
rectovaginal septum and vagina (N80.4-), and intestine (N80.5-), have
been expanded to identify endometriosis of specific sites, laterality,
and depth (superficial, deep, and unspecified).

New codes have been created for endometriosis of the bladder and
ureters (N80.A-), cardiothoracic space (N80.B-), abdomen (N80.C-),
and pelvic nerves (N80.D-). The codes also identify specific sites,
laterality, and depth.

• N80.00-N80.03, Endometriosis of uterus and adenomyosis

of uterus
• N80.101-N80.129, Endometriosis of ovary(ies)
• N80.201-N80.229, Endometriosis of fallopian tube(s)
• N80.30, Endometriosis of pelvic peritoneum, unspecified
• N80.311-N80.329, Endometriosis of cul-de-sac
• N80.331-N80.359, Endometriosis of pelvic sidewall
• N80.361-N80.389, Endometriosis of pelvic brim
• N80.391-N80.399, Endometriosis of pelvic peritoneum

34 Fourth Quarter 2022 Coding Clinic

 • N80.3A1-N80.3C9, Endometriosis of uterosacral
ligament(s)
• N80.40-N80.42, Endometriosis of the rectovaginal septum
and vagina
• N80.50-N80.569, Endometriosis of intestine, rectum,
sigmoid colon, cecum, appendix, other parts of colon, and
small intestine
• N80.A0- N80.A69, Endometriosis of bladder and ureter(s)
• N80.B1-N80.B6, Endometriosis of pleura, lung, diaphragm,
pericardial space, mediastinal space, and cardiothoracic
space
• N80.C0-N80.C9, Endometriosis of abdomen, abdominal
wall, umbilicus, inguinal canal, extra-pelvic abdominal
peritoneum, and other site of abdomen
• N80.D0-N80.D9, Endometriosis of pelvic nerves, sacral
splanchnic nerves, sacral nerve roots, obturator nerve,
sciatic nerve, pudendal nerve, femoral nerve, and other
pelvic nerve

Endometriosis is a common gynecological disorder, affecting women

of childbearing age. Women with endometriosis develop tissue,
outside of the uterus, that resembles and behaves like endometrial
tissue. Endometriosis typically involves the fallopian tubes, ovaries,
and tissue lining the pelvis, and may be located beyond the area
where the pelvic organs are in rare cases. The primary symptom of
endometriosis is pelvic pain, often associated with menstrual periods.
Patients with endometriosis are more likely to have infertility issues.
Endometriosis may be described as superficial or deeply infiltrating.

Previously, ICD-10-CM codes for endometriosis did not provide

detail regarding laterality and depth of invasion and were limited in
identifying specific locations. The expansion of these subcategories
for endometriosis will enable better tracking and treatment of
endometriosis.

Question:
A patient experiencing severe abdominal pain
was diagnosed with superficial endometriosis of
the right ovary, following a laparoscopy. What
is the correct code assignment for superficial
endometriosis of the right ovary?

Coding Clinic Fourth Quarter 2022 35

 Answer:
Assign code N80.111, Superficial endometriosis
of the right ovary.

Question:
A patient complained of excessive menstrual
cramps and pain during intercourse. The
provider diagnosed deep endometriosis of
the pelvic sidewall. What is the correct code
assignment for the endometriosis?

Answer:
Assign code N80.349, Deep endometriosis of
the pelvic sidewall, unspecified side.

Isthmocele

Code N85.A, Isthmocele, was created to identify isthmocele for the

gynecologic (non-pregnant) patient population.

An isthmocele (cesarean scar defect) is any indentation indicating

myometrial discontinuity or a triangular anechoic defect in the anterior
uterine wall, at the location of a previous cesarean section scar. It is
typically asymptomatic; however, a patient may experience chronic
pelvic pain and abnormal or postmenstrual bleeding. Uterine rupture,
infertility, scar dehiscence, cesarean scar ectopic pregnancy, and
placenta accreta or placenta previa may be complications of an
isthmocele.

The risk factors for this condition include multiple cesarean sections,
retroflexed uterus, failure of the hysterotomy to completely close,
uterine wall adhesions, lower position of a cesarean section, and a
genetic predisposition.

ICD-10-CM has codes describing isthmocele in the obstetric setting

(subcategory O34.2-, Maternal care due to uterine scar from
previous surgery). However, previously there was no diagnosis code
for isthmocele in gynecology patients. The new code will allow for
tracking the frequency of isthmocele, and enable identification of
effective treatment modalities.

36 Fourth Quarter 2022 Coding Clinic

When assigning the new code for isthmocele, code also any
associated conditions if applicable.

Question:
A non-pregnant patient experiencing chronic
pelvic pain and postmenstrual bleeding
underwent diagnostic hysteroscopy, and the
provider diagnosed, “Lower uterine segment
isthmocele.” She underwent excision of
the isthmocele. What is the correct code
assignment for isthmocele in a non-pregnant
patient?

Answer:
Assign code N85.A, Isthmocele, for the lower
uterine segment isthmocele in a non-pregnant
patient.

Maternal Care for (Suspected) Fetal Anomalies

Subcategory O35.0, Maternal care for (suspected) central nervous

system malformation in fetus, has been expanded to distinguish
various central nervous system anomalies in the fetus. In addition,
new codes have been created for maternal care for (suspected)
chromosomal abnormalities (O35.1-), as well as facial (O35.A-),
cardiac (O35.B-), pulmonary (O35.C-), gastrointestinal (O35.D-),
genitourinary (O35.E-), musculoskeletal (O35.F-), and upper/lower
extremities (O35.G- and O35.H-) anomalies in the fetus. These
codes require a seventh character to identify the fetus in a multiple
gestational pregnancy for which the complication code applies. The
seventh character 0, not applicable or unspecified, is used for single
gestations.

Previously maternal care for certain fetal central nervous system

malformations, such as anencephaly, hydrocephalus and spina bifida
were all classified to the same code. These new codes were created
to help measure the incidence of these specific anomalies, which is
important in terms of public health, as these codes will allow tracking
of these different conditions.

Coding Clinic Fourth Quarter 2022 37

 Apnea of Newborn

Code P28.3, Primary sleep apnea of newborn, and code P28.4, Other
apnea of newborn have been expanded with unique codes to describe
the distinct types of primary sleep apnea of newborn, and specific
types of apneas (of prematurity) that occur outside of sleep. The new
codes follow:

• P28.30, Primary sleep apnea of newborn, unspecified

• P28.31, Primary central sleep apnea of newborn
• P28.32, Primary obstructive sleep apnea of newborn
• P28.33, Primary mixed sleep apnea of newborn
• P28.39, Other primary sleep apnea of newborn
• P28.40, Unspecified apnea of newborn
• P28.41, Central neonatal apnea of newborn
• P28.42, Obstructive apnea of newborn
• P28.43, Mixed neonatal apnea of newborn
• P28.49, Other apnea of newborn

An apneic spell refers to the interruption of breathing for 20 seconds

or longer or a shorter pause accompanied by bradycardia (<100
beats per minute) cyanosis, and/or pallor. Apnea may be classified as
central (cessation of breathing effort), obstructive (airflow obstruction
usually at the pharyngeal level), or mixed. The condition can occur
in any newborn, but apnea of prematurity is distinct from newborn
sleep apnea. Apnea of prematurity is a developmental disorder
caused by immaturity of neurologic and/or mechanical function of the
respiratory system. While apnea of prematurity can be diagnosed
based on clinical findings, sleep apnea is diagnosed based on
polysomnography.

Central apnea is the most common type of apnea of prematurity

and is caused by immature medullary respiratory control centers.
The specific pathophysiology involves several factors, including
abnormal responses to hypoxia and hypercapnia. Obstructive apnea
is caused by obstructed airflow, neck flexion causing opposition of
hypopharyngeal soft tissues, nasal occlusion, or reflex laryngospasm.
Mixed apnea is a combination of central and obstructive apnea.

All types of apneas can cause hypoxemia, cyanosis, and bradycardia

when the spell is prolonged. Because bradycardia can also occur
simultaneously with apnea, a central mechanism may be responsible

38 Fourth Quarter 2022 Coding Clinic

for both. About 18% of infants who have died of sudden infant
death syndrome (SIDS) had a history of prematurity, but apnea of
prematurity is not a precursor to SIDS.

Typically, mixed and obstructive apnea is managed with supplemental

oxygen and continuous positive airway pressure (CPAP) ventilation.
Occasionally surgical intervention, such as palatoplasty or in extreme
cases tracheostomy, may be required. In addition, central apnea may
require medications to help stimulate the respiratory centers in the
brain.

When assigning the new codes for apnea of newborn, code also, if
applicable any congenital malformations of the respiratory system.

Congenital Atrial Septal and Atrioventricular

Septal Defect and Patent Foramen Ovale

Two new subcategories with specific codes to identify different types

of atrial septal and atrioventricular septal defects, as well as a unique
code for patent foramen ovale have been created. The new codes are
as follows:

• Q21.10, Atrial septal defect, unspecified

• Q21.11, Secundum atrial septal defect
• Q21.12, Patent foramen ovale
• Q21.13, Coronary sinus atrial septal defect
• Q21.14, Superior sinus venosus atrial septal defect
• Q21.15, Inferior sinus venosus atrial septal defect
• Q21.16, Sinus venosus atrial septal defect, unspecified
• Q21.19, Other specified atrial septal defect
• Q21.20, Atrioventricular septal defect, unspecified as to
partial or complete
• Q21.21, Partial atrioventricular septal defect
• Q21.22, Transitional atrioventricular septal defect
• Q21.23, Complete atrioventricular septal defect

Atrial septal defect (ASD) and atrioventricular septal defect (AVSD)

are common congenital heart anomalies. An ASD is a hole in the
wall (septum) that divides the upper chambers (atria) of the heart.
Conversely, an AVSD involves holes in the wall that divides the right
and left chambers (ventricles) of the heart. The AVSD may be partial,
involving only the atria or the ventricles, or complete, involving all four

Coding Clinic Fourth Quarter 2022 39

chambers. A complete AVSD may also involve incomplete closure of
the mitral valve that allows blood to flow back from the left ventricle
into the left atrium. An ostium primum atrial septal defect is a partial
atrioventricular septal defect.

Previously, ASD and patent foramen ovale (PFO) were classified to

the same code. However, classifying two different heart conditions to
the same code was problematic. For surveillance purposes, an ASD is
considered a major malformation, whereas a PFO is a normal variant
in the newborn period, which typically closes during infancy. These
new codes will help to differentiate these heart anomalies, improve
data quality for surveillance and research purposes, and possibly
advance the care of these patients.

PTEN Hamartoma Tumor Syndrome, Cowden

Syndrome, and von Hippel-Lindau Syndrome

Code Q85.8, Other phakomatoses, not elsewhere classified, was

expanded and unique codes have been created to describe PTEN
tumor syndrome (Q85.81), other Cowden syndrome (Q85.82), and
von Hippel-Lindau syndrome (Q85.83).

PTEN hamartoma tumor syndrome (PHTS) is an uncommon

condition that includes a spectrum of disorders caused by a germline
heterozygous loss-of-function mutation in the Phosphatase and
Tensin Homolog (PTEN) tumor suppressor gene. The syndrome is
characterized by multiple hamartomas (benign tumors) that can affect
various areas of the body. Estimating the prevalence of PHTS is
difficult, because of the varied clinical presentations, and signs and
symptoms that can vary in severity. Aside from benign hamartomas,
the range of clinical manifestations may include macrocephaly,
learning and developmental delays, neurocognitive deficits, such as
autism spectrum disorder, and cognitive impairment. These patients
also have an increased risk of developing a malignancy.

Cowden syndrome (CS), also referred to as Cowden disease and

multiple hamartoma syndrome, is a rare genetic condition that is along
the PHTS syndrome spectrum. The syndrome is caused by mutations
in the PTEN gene and is characterized by hamartomas, with a risk
for developing cancer. In CS, hamartomas can form in various areas
of the body, including the skin, mouth, and gastrointestinal tract.

40 Fourth Quarter 2022 Coding Clinic

Other benign tumors can also occur in the thyroid, breast, uterus, soft
tissue, and brain. Signs and symptoms of the syndrome may include
an enlarged head, atypical skin changes, blood vessel issues, autism
spectrum disorder and learning and developmental delays. Individuals
affected with CS may have an increased risk of cancer, such as
melanoma and malignant tumors of the breast, thyroid, endometrium,
kidney, colon, and rectum.

Von Hippel-Lindau syndrome, also referred to as VHL disease, VHL

syndrome, and von Hippel-Lindau disease, is a rare genetic condition
that is caused by a mutation in the VHL gene. VHL syndrome causes
tumors and cysts to grow in certain parts of the body, including the
brain, spinal cord, eyes, inner ear, adrenal glands, pancreas, kidney,
and reproductive tract. Typically, these tumors are benign, but may be
malignant, in some cases. Persons with VHL syndrome may have an
increased risk of malignancy, such as kidney and pancreatic cancer.

These codes will help to improve patient care by tracking outcomes of

clinical interventions, and by facilitating the development of standard
care protocols.

Question:
A patient with PTEN hamartoma tumor
syndrome (PHTS) was seen in the clinic for
further evaluation. The patient also had a
history of a developmental learning delay,
macrocephaly and autism spectrum disorder.
How would this visit be coded?

Answer:
Assign code Q85.81, PTEN tumor syndrome,
as the first-listed diagnosis for the PHTS.
Assign codes Q75.3, Macrocephaly, F84.0,
Autistic disorder, and F81.9, Developmental
disorder of scholastic skills, unspecified, as
additional diagnoses. When present, the
manifestations of PHTS, such as macrocephaly,
autism and learning delay are separately coded
since the range of manifestations can differ in
each patient.

Coding Clinic Fourth Quarter 2022 41

 Intracranial Injury with Unknown Loss
of Consciousness

Category S06, Intracranial injury, has been expanded, and unique

codes have been created to identify patients where it is unknown
whether the patient has experienced loss of consciousness (LOC).
These new codes capture distinct types of intracranial injuries when
the LOC status is unknown, and also include a seventh character
extension to describe A, initial encounter, D, subsequent encounter,
and S, sequela. New codes have also been created to describe
intracranial injuries of the right and left internal carotid artery. Lastly,
we also have new codes to identify a primary blast injury of the brain
not elsewhere classified with varying durations of LOC. The new
codes are listed below:

• S06.0XA- Concussion with loss of consciousness

status unknown
• S06.1XA- Traumatic cerebral edema with loss of
consciousness status unknown
• S06.2XA- Diffuse traumatic brain injury with loss of
consciousness status unknown
• S06.30A- Unspecified focal traumatic brain injury with
loss of consciousness status unknown
• S06.31A- Contusion and laceration of right cerebrum
with loss of consciousness status unknown
• S06.32A- Contusion and laceration of left cerebrum
with loss of consciousness status unknown
• S06.33A- Contusion and laceration of cerebrum,
unspecified, with loss of consciousness
status unknown
• S06.34A- Traumatic hemorrhage of right cerebrum
with loss of consciousness status unknown
• S06.35A- Traumatic hemorrhage of left cerebrum with
loss of consciousness status unknown
• S06.36A- Traumatic hemorrhage of cerebrum,
unspecified, with loss of consciousness
status unknown
• S06.37A- Contusion, laceration, and hemorrhage of
cerebellum with loss of consciousness
status unknown

42 Fourth Quarter 2022 Coding Clinic

 • S06.38A- Contusion, laceration, and hemorrhage of
brainstem with loss of consciousness
status unknown
• S06.4XA- Epidural hemorrhage with loss of
consciousness status unknown
• S06.5XA- Traumatic subdural hemorrhage with
loss of consciousness status unknown
• S06.6XA- Traumatic subarachnoid hemorrhage with
loss of consciousness status unknown
• S06.81A- Injury of right internal carotid artery,
intracranial portion, not elsewhere classified
with loss of consciousness status unknown
• S06.82A- Injury of left internal carotid artery,
intracranial portion, not elsewhere classified
with loss of consciousness status unknown
• S06.8A0- Primary blast injury of brain, not elsewhere
classified without loss of consciousness
• S06.8A1- Primary blast injury of brain, not elsewhere
classified with loss of consciousness of 30
minutes or less
• S06.8A2- Primary blast injury of brain, not elsewhere
classified with loss of consciousness of 31
minutes to 59 minutes
• S06.8A3- Primary blast injury of brain, not elsewhere
classified with loss of consciousness of 1
hour to 5 hours 59 minutes
• S06.8A4- Primary blast injury of brain, not elsewhere
classified with loss of consciousness of 6
hours to 24 hours
• S06.8A5- Primary blast injury of brain, not elsewhere
classified with loss of consciousness
greater than 24 hours with return to pre-
existing conscious level
• S06.8A6- Primary blast injury of brain, not elsewhere
classified with loss of consciousness
greater than 24 hours without return to
pre-existing conscious level with patient
surviving
• S06.8A7- Primary blast injury of brain, not elsewhere
classified with loss of consciousness of any
duration with death due to brain injury prior
to regaining consciousness

Coding Clinic Fourth Quarter 2022 43

 • S06.8A8- Primary blast injury of brain, not elsewhere
classified with loss of consciousness of any
duration with death due to other cause prior
to regaining consciousness
• S06.8AA- Primary blast injury of brain, not elsewhere
classified with loss of consciousness status
unknown
• S06.8A9- Primary blast injury of brain, not elsewhere
classified with loss of consciousness of
unspecified duration
• S06.89A- Other specified intracranial injury with loss
of consciousness status unknown
• S06.9XA- Unspecified intracranial injury with loss of
consciousness status unknown

Often patients will present with injuries that are classified to

category S06, Intracranial injury, without a clear history of LOC
status. Previously, these cases defaulted to codes for “with loss of
consciousness of unspecified duration.” However, this implied the
patient had a LOC, which may not always be the case.

The creation of these new codes will allow for better tracking of
patients, in which LOC is either unknown or not specified.

Question:
A patient with a history of dementia presented
to the emergency department following a fall.
Although the patient was alert when the family
of the patient found her on the floor, they were
unsure if there was any loss of consciousness
(LOC). The patient was diagnosed with both
a subarachnoid hemorrhage (SAH) and a
subdural hemorrhage (SDH). The physician
was queried regarding whether there was loss
of consciousness associated with the fall and
the provider stated they could not verify if there
was any LOC. What is the appropriate 6th
character to describe unknown or unspecified
loss of consciousness?

44 Fourth Quarter 2022 Coding Clinic

 Answer:
Assign codes S06.6XAA, Traumatic
subarachnoid hemorrhage loss of
consciousness status unknown, initial
encounter, S06.5XAA, Traumatic subdural
hemorrhage loss of consciousness status
unknown, initial encounter, and W19.XXXA,
Unspecified fall, initial encounter, for the
subarachnoid and subdural hemorrhages
secondary to a fall.

Codes in category S06, Intracranial injury,

include a 6th character “A” which describes
unknown or unspecified loss of consciousness.

Poisoning by, Adverse Effect of, and Underdosing

of Methamphetamines

Subcategory T43.65, Poisoning by, adverse effect of and underdosing

of methamphetamines, has been created along with new codes to
specifically identify methamphetamine poisoning, adverse effects, and
underdosing:

• T43.651, Poisoning by methamphetamines, accidental

(unintentional)
• T43.652, Poisoning by methamphetamines, intentional
self-harm
• T43.653, Poisoning by methamphetamines, assault
• T43.654, Poisoning by methamphetamines, undetermined
• T43.655, Adverse effect of methamphetamines
• T43.656, Underdosing of methamphetamines

Methamphetamine (meth) is a stimulant. Meth is an illicit highly

addictive drug with potent central nervous system stimulant
properties. Smoking or injecting meth may cause one to experience
a rush, while oral ingestion or snorting may produce a long-
lasting high. Both the rush and high are believed to be due to high
levels of dopamine in areas of the brain that regulate feelings of
pleasure. Dopamine is involved in body movement, motivation, and
reinforcement of rewarding behaviors.

Coding Clinic Fourth Quarter 2022 45

Desoxyn® is methamphetamine, a prescription stimulant that is
approved by the Food and Drug Administration to treat attention deficit
hyperactivity disorder.

Previously, poisoning by, adverse effect of, and underdosing of

methamphetamines were classified to subcategory T43.62, Poisoning
by, adverse effect of and underdosing of amphetamines. Subcategory
T43.62 was not specific to methamphetamines, and classifying
methamphetamines with other amphetamines, such as prescription
dextroamphetamine/amphetamine, resulted in difficulty tracking
methamphetamines specifically.

The new codes will allow specific tracking, trending and

research of poisoning by, adverse effect of, and underdosing of
methamphetamines.

Question:
A patient presents to the Emergency
Department after experiencing convulsions.
He admitted to using a large amount of meth
while getting high with friends. The provider
diagnosed methamphetamine overdose.
What is the correct code assignment for the
overdose?

Answer:
Assign code T43.651A, Poisoning by
methamphetamines, accidental (unintentional),
initial encounter, followed by codes R56.9,
Unspecified convulsions, and F15.90, Other
stimulant use, unspecified, uncomplicated, for
the methamphetamine overdose.

Question:
A patient prescribed Desoxyn® for attention
deficit hyperactivity disorder (ADHD)
experienced rapid heart rate. The provider’s
documentation states that the rapid heart
rate was an adverse effect of the prescribed
Desoxyn®. What is the correct code
assignment for this patient?

46 Fourth Quarter 2022 Coding Clinic

 Answer:
Assign code R00.0, Tachycardia, unspecified,
followed by code T43.655A, Adverse effect of
methamphetamines, initial encounter.

External Cause of Injury Codes for

Electric Assisted Bicycles
Codes in categories V20-V29 (Motorcycle rider injured in transport
accident) have been expanded and new codes created to capture the
external cause of injuries to persons (driver, passenger, unspecified
motorcycle rider, person boarding or alighting) on electric bicycles
(e-bicycles), and other motorcycles, and unspecified e-bicycles, who
are injured during traffic or non-traffic accidents involving collision or
non-collision.

The codes for collision uniquely identify whether the collision is with a
pedestrian, animal, or other source (pedal cycle, two or three wheeled
motor vehicle, car, pick-up truck or van, heavy transport vehicle or
bus, railway train or railway vehicle, other non-motor vehicle, fixed or
stationary object, transport accident, or unspecified motor vehicle).

E-bicycles are equipped with a battery, and typically have two or three
wheels that are set in motion partially or entirely by electric power.
Although e-bicycles have become popular modes of transportation,
there was lack of reliable injury epidemiology data for these devices.

Since these modes of transportation differ from motorcycles with

regards to speed of travel, regulations, ridership, and where they
may be ridden, it is vital that unique codes be created within the
“motorcycle” section of ICD-10-CM to capture e-bicycle injuries.

Previously, ICD-10-CM External Cause of Morbidity codes did not

distinguish injuries sustained on e-bicycles from those sustained on
motorcycles. Additionally, ICD-10-CM was not suitable for e-bicycle
injury surveillance at the local, state, or national level. Introduction of
e-bicycle-specific ICD-10-CM External Cause of Morbidity codes will
reduce the possibility of misclassification.

Coding Clinic Fourth Quarter 2022 47

 Exposure to Inanimate Mechanical Forces
Caught, Crushed, Jammed, or Pinched in
or Between Objects

New codes (W23.2-) were created to identify patients who were

injured because of being caught, crushed, jammed, or pinched
between a moving and stationary object.

According to the Occupational Safety & Health Administration

(OSHA), caught-in or caught-between hazards are defined as injuries
resulting from a person being caught, pinched, squeezed, crushed,
or compressed between two or more objects, or between parts of an
object. This definition includes individuals who are caught or crushed
between operating equipment, mashing objects, a moving and
stationary object, or between two or more moving objects. The OSHA
definition also includes being crushed or compressed between objects
that slide, roll, or shift, and being caught or pulled into equipment or
machinery, and strangulation from clothing caught in machinery and
equipment.

Previously, ICD-10-CM did not include an external cause code to

identify patients injured during these types of events. Adding the
new codes will allow the ability to analyze these types of external
causes and contribute to the accuracy of healthcare statistics on
external causes as reflected in provider clinical documentation. The
data will also contribute to occupational health statistics gathered by
organizations such as OSHA.

48 Fourth Quarter 2022 Coding Clinic

 Z Codes Update
Status

Codes were created to report a patient’s noncompliance with dietary

regimen, or medical treatment, due to financial hardship, as noted
below:

• Z91.110, Patient’s noncompliance with dietary regimen

due to financial hardship
• Z91.118, Patient’s noncompliance with dietary regimen for
other reason
• Z91.119, Patient’s noncompliance with dietary regimen
due to unspecified reason
• Z91.190, Patient’s noncompliance with other medical
treatment and regimen due to financial hardship
• Z91.198, Patient’s noncompliance with other medical
treatment and regimen for other reason
• Z91.199, Patient’s noncompliance with other medical
treatment and regimen due to unspecified reason

The following codes were also created for instances when the
noncompliance is due to the patient’s primary care giver and not the
patient:

• Z91.A10, Caregiver’s noncompliance with patient’s dietary

regimen due to financial hardship
• Z91.A18, Caregiver’s noncompliance with patient’s dietary
regimen for other reason
• Z91.A20, Caregiver’s intentional underdosing of patient’s
medication regimen due to financial hardship
• Z91.A28, Caregiver’s intentional underdosing of
medication regimen for other reason
• Z91.A3, Caregiver’s unintentional underdosing of patient’s
medication regimen
• Z91.A4, Caregiver’s other noncompliance with patient’s
medication regimen
• Z91.A5, Caregiver’s noncompliance with patient’s renal
dialysis
• Z91.A9, Caregiver’s noncompliance with patient’s other
medical treatment and regimen

Coding Clinic Fourth Quarter 2022 49

New codes were created to allow tracking and monitoring of long-term
(current) drug therapy medications, as follows:

• Z79.60, Long term (current) use of unspecified

immunomodulators and immunosuppressants
• Z79.61, Long term (current) use of immunomodulator
• Z79.620, Long term (current) use of immunosuppressive
biologic
• Z79.621, Long term (current) use of calcineurin inhibitor
• Z79.622, Long term (current) use of Janus kinase inhibitor
• Z79.623, Long term (current) use of mammalian target of
rapamycin (mTOR) inhibitor
• Z79.624, Long term (current) use of inhibitors of
nucleotide synthesis
• Z79.630. Long term (current) use of alkylating agent
• Z79.631, Long term (current) use of antimetabolite
agent
• Z79.632, Long term (current) use of antitumor antibiotic
• Z79.633, Long term (current) use of mitotic inhibitor
• Z79.634, Long term (current) use of topoisomerase
inhibitor
• Z79.64, Long term (current) use of myelosuppressive
agent
• Z79.69, Long term (current) use of other
immunomodulators and immunosuppressants
• Z79.85, Long-term (current) use of injectable non-insulin
antidiabetic drugs

History (of)

There are nine new personal history codes:

• Z87.61, Personal history of (corrected) necrotizing

enterocolitis of newborn
• Z87.68, Personal history of other (corrected) conditions
arising in the perinatal period
• Z87.731, Personal history of (corrected)
tracheoesophageal fistula or atresia
• Z87.732, Personal history of (corrected) persistent cloaca
or cloacal malformations

50 Fourth Quarter 2022 Coding Clinic

 • Z87.760, Personal history of (corrected) congenital
diaphragmatic hernia or other congenital diaphragm
malformations
• Z87.761, Personal history of (corrected) gastroschisis
• Z87.762, Personal history of (corrected) prune belly
malformation
• Z87.763, Personal history of other (corrected) congenital
abdominal wall malformations
• Z87.768, Personal history of other specified (corrected)
congenital malformations of integument, limbs and
musculoskeletal system

Observation

Code Z03.83, Encounter for observation for suspected conditions

related to home physiologic monitoring device ruled out, was
created to capture when a home physiologic monitoring device
goes off indicating there is a problem, but there are no signs and
symptoms, diagnosis, or clinical findings after examination and review
of the data.

Counseling

Code Z71.87, Encounter for pediatric-to-adult transition

counseling, was created for transitional counseling related to
integrating youth into young adult care for health care issues,
such as self-care, health literacy, decreased parental involvement,
reproductive health, etc. The patient may be with or without special
health care needs (chronic disease, mental disorders or disabilities).

Code Z71.88, Encounter for counseling for socioeconomic

factors, was created to represent the effort to assess and set patient-
centered goals that address socioeconomic risks.

Code Z72.823, Risk of suffocation (smothering) under another

while sleeping, identifies the risk of suffocation of a newborn/infant
due to sharing sleeping arrangements with an adult.

Coding Clinic Fourth Quarter 2022 51

Social Determinants of Health

New codes have been created to provide additional information

regarding social determinants of health (SDOH) in subcategory Z59.8,
Other problems related to housing and economic circumstances.
Code Z59.82 describes transportation insecurity that affects a
person’s access to health care services. Code Z59.86 identifies
financial insecurity or an inadequacy of financial resources; and code
Z59.87 captures material hardship or the inability to obtain basic
needs. These codes identify risks that are beyond low income and
poverty thresholds.
 

52 Fourth Quarter 2022 Coding Clinic

 NEW/REVISED
ICD-10-PCS CODES
A summary of the Fiscal Year 2023 (FY 2023) ICD-10-PCS changes
effective October 1, 2022 is provided below. The addenda changes
demonstrating the specific revisions to the code titles are not included
in the explanations below. The FY 2023 ICD-10-PCS updates,
including the complete list of ICD-10-PCS code titles, addenda, and
a conversion Table showing changes from the previous year are
available on the Centers for Medicare & Medicaid Services (CMS)
website at https://www.cms.gov/medicare/icd-10/2023-icd-10-pcs.

There are 331 new ICD-10-PCS codes effective October 1, 2023.

There were 0 revised code titles, and 64 codes were deleted.

Most new codes are in Section 0-Medical and Surgical and Section
X-New Technology. There are also a small number of changes in
Sections 3-Administration, 5-Extracorporeal or Systemic Assistance
and Performance, B-Imaging, and D-Radiation Therapy.

The specific changes are described below by section. Additions are

shown as underlined, and deletions are shown as strikeouts in the
excerpts from the ICD-10-PCS Tables below. The changes originate
from public comments, CMS internal review, as well as questions
submitted to Coding Clinic discussed by the Editorial Advisory Board
for Coding Clinic with recommendations for more specific values.

Section 0 – Medical and Surgical

Laser Interstitial Thermal Therapy (LITT)

Effective with FY 2023 changes, 31 codes for Laser Interstitial

Thermal Therapy (LITT) were deleted from tables in the Radiation
Therapy Section (D) and reclassified to the Medical and Surgical
Section (0) to more accurately capture LITT as thermal therapy rather
than as radiation therapy. LITT uses heat generated by a laser probe
to destroy soft tissue at targeted sites.

Qualifier value 3 for Laser Interstitial Thermal Therapy has been

added to capture LITT ablation at the following tables:

Coding Clinic Fourth Quarter 2022 53

 • 005 Destruction of Central Nervous System and Cranial Nerves
• 0B5 Destruction of Respiratory System
• 0D5 Destruction of Gastrointestinal System
• 0F5 Destruction of Hepatobiliary System and Pancreas
• 0G5 Destruction of Endocrine System
• 0H5 Destruction of Skin and Breast
• 0V5 Destruction of Male Reproductive System

Ultrasonic Surgical Aspiration of Brain

In table 00D, Extraction of Central Nervous System and Cranial

Nerves, body part value C for Cerebellum, has been added to identify
procedures to remove tumors of the cerebellum such as Cavitron
Ultrasonic Surgical Aspiration (CUSA), as discussed in Coding Clinic,
Fourth Quarter 2021, pages 38-40.

Body Part Approach Device Qualifier

C Cerebellum 0 Open Z No Device Z No Qualifier
3 Percutaneous
4 Percutaneous
Endoscopic

Rapid Deployment Technique for Replacement

of Aortic Valve using Zooplastic Tissue

The rapid deployment technique for aortic valve replacement has

been reassigned from the New Technology Section (X) to the
Medical and Surgical Section (0). The following codes that identify
replacement of the aortic valve with zooplastic tissue using the rapid
deployment technique were deleted:

X2RF032 Replacement of aortic valve using zooplastic tissue,

rapid deployment technique, open approach, new
technology group 2

X2RF332 Replacement of aortic valve using zooplastic tissue,

rapid deployment technique, percutaneous approach,
new technology group 2

X2RF432 Replacement of aortic valve using zooplastic tissue,

rapid deployment technique, percutaneous endoscopic
approach, new technology group 2

54 Fourth Quarter 2022 Coding Clinic

At table 02R, Replacement of Heart and Great Vessels, device
value, 8 Zooplastic Tissue and qualifier value, N Rapid Deployment
Technique, were added to identify rapid deployment technique of
aortic valve replacement. This technique typically requires less time to
deploy the valve and requires minimal sutures to secure it, resulting in
smaller incisions and a shorter operative time.

Body Part Approach Device Qualifier

F Aortic Valve 0 Open 8 Zooplastic N Rapid
3 Percutaneous Tissue Deployment
4 Percutaneous Technique
Endoscopic Z No Qualifier

Embolization of Prostatic Arteries

In table 04L, Occlusion of Lower Arteries, new qualifier values V

Prostatic Artery, Right and W Prostatic Artery, Left have been added
for the body part values E Internal Iliac Artery, Right and F Internal
Iliac Artery, Left. The changes enable capture of detail for procedures
such as the embolization of a prostatic artery.

Body Part Approach Device Qualifier

E Internal Iliac 0 Open C Extraluminal T Uterine
Artery, Right 3 Percutaneous Device Artery, Right
4 Percutaneous D Intraluminal V Prostatic
Endoscopic Device Artery, Right
Z No Device Z No Qualifier
F Internal Iliac 0 Open C Extraluminal U Uterine
Artery, Left 3 Percutaneous Device Artery, Left
4 Percutaneous D Intraluminal W Prostatic
Endoscopic Device Artery, Left
Z No Device Z No Qualifier

Prostatic artery embolization (PAE) treats benign prostatic hyperplasia

(BPH) by occluding blood flow to the prostate. During PAE, imaging
is utilized to guide catheter placement into the arteries that feed
the prostate gland. Microscopic plastic beads or Embosphere® are
injected into the arteries to stop blood flow and shrink the prostate.

Coding Clinic Fourth Quarter 2022 55

 Question:
A patient with benign prostatic hyperplasia
causing symptoms of hematuria and dysuria
presented for bilateral prostate artery
embolization. During the procedure, the right
common femoral artery was cannulated along
with the contralateral left internal iliac artery
and multiple attempts were made to cannulate
the left prostate artery. Despite the effort, the
left prostate artery could not be successfully
cannulated. Subsequently, the right internal
iliac artery was selectively cannulated and
Embosphere® particles were instilled into
the right prostate artery. Once stagnant flow
was identified within the right prostate artery,
imaging showed complete occlusion with
preservation of its vesical branches. What is
the appropriate ICD-10-PCS code for prostate
artery embolization?

Answer:
Assign the following ICD-10-PCS codes:

04LE3DV Occlusion of right prostatic

artery with intraluminal device,
percutaneous approach, for
embolization of the right
prostatic artery utilizing
Embosphere® particles, and

04JY3ZZ Inspection of lower artery,

percutaneous approach, for the
attempted cannulation of the left
prostate artery.

Bladder Augmentation

In table 0DX, Transfer of Gastrointestinal System, a new qualifier

value B Bladder was added to the body part values 8 Small Intestine
and E Large Intestine, to capture procedures such as bladder
augmentation using an isolated section of the intestine (usually the
ileum, cecum, or sigmoid) that is still connected to its vascular and
nervous supply.

56 Fourth Quarter 2022 Coding Clinic

Body Part Approach Device Qualifier
8 Small 0 Open Z No Device 5 Esophagus
Intestine 4 Percutaneous B Bladder
Endoscopic

Body Part Approach Device Qualifier

E Large 0 Open Z No Device 5 Esophagus
Intestine 4 Percutaneous 7 Vagina
Endoscopic B Bladder

Bladder augmentation or augmentation cystoplasty enlarges the

bladder to increase reservoir capacity in patients who have difficulty
storing urine due to acquired or congenital conditions. These
conditions can result in incontinence or increased pressure in the
bladder that may cause urine to back up into the kidneys. During the
procedure, the bladder is opened transversely. A piece of intestine
is isolated, detubularized, and made into a patch while retaining its
vascular supply. The patch of intestine is sutured into position creating
an augmented bladder.

Question:
A patient with urinary incontinence underwent
an augmentation cystoplasty. A midline incision
was made, and the bladder was exposed,
bivalved and opened fully from the bladder
neck to the trigone. A segment of ileum
was selected that could reach the native
bladder without tension. The mesentery was
cleared and the ileum was folded, shaped
and anastomosed to the bivalved bladder in
two-layered absorbable sutures. What is the
appropriate ICD-10-PCS code for bladder
augmentation using a segment of ileum that
remains attached to its vascular and nervous
supply?

Answer:
Assign the following PCS code:

0DX80ZB Transfer small intestine to

bladder, open approach

Coding Clinic Fourth Quarter 2022 57

 Ileal Ureter

Qualifier values C, D, and F were also added for Right, Left and
Bilateral Ureters at the body part value 8 Small Intestine in table
0DX, Transfer of Gastrointestinal System, to capture procedures that
use a segment of the small intestine to function as the ureter while
remaining connected to its vascular and nervous supply.

Body Part Approach Device Qualifier

8 Small 0 Open Z No Device 5 Esophagus
Intestine 4 Percutaneous C Ureter, Right
Endoscopic D Ureter, Left
F Ureters,
Bilateral

Infusion Device in Head and Facial Bones

In tables 0NP, Removal of Head and Facial Bones, and 0NW,

Revision of Head and Facial Bones, device value 3 Infusion Device
has been added to the body part value 0 Skull, to capture removal
and revision procedures performed on previously inserted infusion
devices, such as the Ommaya reservoir.

Section: 0 Medical and Surgical

Body System: N Head and Facial Bones
Operation: P Removal
Body Part Approach Device Qualifier
0 Skull 0 Open 3 Infusion Z No Qualifier
3 Percutaneous Device
4 Percutaneous
Endoscopic
X External

58 Fourth Quarter 2022 Coding Clinic

Section: 0 Medical and Surgical
Body System: N Head and Facial Bones
Operation: W Revision
Body Part Approach Device Qualifier
0 Skull 0 Open 3 Infusion Z No Qualifier
3 Percutaneous Device
4 Percutaneous
Endoscopic
X External

Drainage of the Parapharyngeal Space and

Retropharyngeal Space

In table 0W9, Drainage of General Anatomical Regions, the approach

values 7 Via Natural or Artificial Opening, and 8 Via Natural or Artificial
Opening Endoscopic, were added to body part value 6 Neck, to
enable capture of procedures such as drainage of retropharyngeal/
parapharyngeal abscesses using a fiberoptic laryngoscope.

Body Approach Device Qualifier

Part
6 Neck 0 Open 0 Drainage Z No Qualifier
3 Percutaneous Device
4 Percutaneous
Endoscopic
7 Via Natural or
Artificial Opening
8 Via Natural or Artificial
Opening Endoscopic
6 Neck 0 Open Z No Device X Diagnostic
3 Percutaneous Z No Qualifier
4 Percutaneous
Endoscopic
7 Via Natural or
Artificial Opening
8 Via Natural or Artificial
Opening Endoscopic

Coding Clinic Fourth Quarter 2022 59

 Question:
A patient was admitted for incision and
drainage of a large parapharyngeal abscess.
The procedure was performed endoscopically
using flexible fiberoptic laryngoscopy. What
is the appropriate ICD-10-PCS code for the
procedure?

Answer:
Assign the following PCS code:

0W968ZZ Drainage of neck, via natural or

artificial opening endoscopic.

Section 3 – Administration
Introduction of Other Therapeutic Monoclonal Antibody

In the Administration Section, table 3E0, Introduction of Physiological

Systems and Anatomical Regions, the qualifier value R Other
Therapeutic Monoclonal Antibody, was added to body system/region
values 3 Peripheral Vein and 4 Central Vein. This change will identify
the administration of monoclonal antibodies such as bezlotoxumab
(ZINPLAVA™), when used for non-neoplastic and non-COVID related
indications.

Body System/ Approach Substance Qualifier

Region
3 Peripheral 3 Percutaneous G Other R Other
Vein Therapeutic Therapeutic
4 Central Vein Substance Monoclonal
Antibody

In Section X, New Technology, table XW0, Introduction of Anatomical

Regions, the following codes that uniquely identified the introduction
of bezlotoxumab monoclonal antibody were deleted:

XW033A3 Introduction of bezlotoxumab monoclonal antibody into

peripheral vein, percutaneous approach, new
technology group 3

60 Fourth Quarter 2022 Coding Clinic

XW043A3 Introduction of bezlotoxumab monoclonal antibody into
central vein, percutaneous approach, new technology
group 3

Introduction of Bone-Substitute Material

In the Administration Section, table 3E0, Introduction of Physiological

Systems and Anatomical Regions, approach values 0 Open and 4
Percutaneous Endoscopic were added to body system/region value
V Bones for qualifier C Other substance, to identify the introduction of
bone-substitute material.

Body System/ Approach Substance Qualifier

Region
V Bones 0 Open G Other C Other
3 Percutaneous Therapeutic Substance
4 Percutaneous Substance
Endoscopic

Section 5 – Extracorporeal or Systemic

Assistance and Performance
Cardiac Perfusion with Intra-Arterial
Supersaturated Oxygen

Code 5A0222C Assistance with cardiac oxygenation,

supersaturated, has been created in table 5A0, Assistance of
Physiological Systems, with function value 2 Oxygenation and
qualifier value C Supersaturated as follows:

Body System Duration Function Qualifier

2 Cardiac 2 Continuous 2 Oxygenation C
Supersaturated

Supersaturated oxygen therapy delivers high concentrations of

oxygen to heart tissue that has been damaged by the reduction in
blood flow and lack of oxygen associated with an acute myocardial
infarction. The patient’s blood is mixed with highly oxygenated saline
to produce a hyperoxemic perfusate that is infused into the coronary

Coding Clinic Fourth Quarter 2022 61

artery following successful percutaneous coronary intervention
procedures. Studies show a reduction in size of the infarction,
improved cardiac function and improved clinical outcomes.

In table 5A0, Assistance of Physiological Systems, the following codes

that identified cardiac perfusion with intra-arterial supersaturated
oxygen were deleted:

5A0512C Extracorporeal supersaturated oxygenation,

intermittent
5A0522C Extracorporeal supersaturated oxygenation, continuous

Section B – Imaging
Hyperpolarized Xenon-129 Gas for Imaging
of Lung Function

In the Imaging Section (B) at table BB3, Magnetic Resonance Imaging

(MRI) of Respiratory System, body part value 4 Lungs, Bilateral, was
added with qualifier character 6 value 3 Hyperpolarized Xenon 129
(Xe-129). This change will allow the reporting of code BB34Z3Z,
Magnetic resonance imaging (MRI) of bilateral lungs using
hyperpolarized xenon 129 (Xe-129) when hyperpolarized Xe-129
gas is used during MRI to visualize lung structures and assess lung
function.

Body Part Contrast Qualifier [6th Qualifier [7th

character] character]
4 Lungs, Bilateral Z None 3 Hyperpolarized Z None
Xenon 129 (Xe-
129)

Section D – Radiation Therapy

Deletion of Qualifier Value for Laser
Interstitial Thermal Therapy

Thirty-one codes with modality qualifier value, K Laser Interstitial

Thermal Therapy were deleted from tables (D0Y, DBY, DDY, DFY,
DGY, DMY, and DVY) in the Radiation Therapy Section. New codes
were created in the Medical and Surgical Section, as described on
page 53 of this issue of Coding Clinic.

62 Fourth Quarter 2022 Coding Clinic

 Section X – New Technology
Implantation of Sphenopalatine Ganglion Stimulator
for Ischemic Stroke

New table X0H, Insertion of Nervous System, provides code

X0HK3Q8, Insertion of neurostimulator lead into sphenopalatine
ganglion, percutaneous approach, new technology group 8, to
describe the implantation of a sphenopalatine ganglion stimulator lead
in treatment of acute ischemic stroke.

Section: X New Technology

Body System: 0 Nervous System
Operation: H Insertion
Body Part Approach Device/ Qualifier
Substance/
Technology
K 3 Percutaneous Q 8 New
Sphenopalatine Neurostimulator Technology
Ganglion Lead Group 8

The sphenopalatine ganglion (SPG) is the source of parasympathetic

innervation to the anterior cerebral circulation. Sphenopalatine
ganglion stimulation (SPGS) increases cerebral collateral blood flow,
improves oxygen availability, and reduces infarct size following acute
ischemic stroke. Collateral blood flow can preserve brain tissue and
improve neurologic function for hours after a major artery to the brain
is blocked.

An implantable neurostimulator is inserted through the greater

palatine canal and positioned with its tip next to the SPG. The SPG is
stimulated by radiofrequency energy that is produced from an external
transmitter.

Question:
A patient suffered an acute right hemispheric
stroke. In order to minimize the impact of the
stroke and to improve collateral circulation,
a sphenopalatine ganglion stimulator was
implanted through the oral cavity and

Coding Clinic Fourth Quarter 2022 63

 pterygopalatine canal and into the vicinity
of the sphenopalatine ganglion. What is
the appropriate ICD-10-PCS code for the
procedure?

Answer:
Assign the following PCS code:

X0HK3Q8 Insertion of neurostimulator lead

into sphenopalatine ganglion,
percutaneous approach, new
technology group 8.

Implantation of Paired Vagus Nerve Stimulator

Using an External Controller

Code X0HQ3R8, Insertion of neurostimulator lead with paired

stimulation system into vagus nerve, percutaneous approach,
new technology group 8, was created in table X0H, Insertion of
Nervous System, to describe paired vagus nerve stimulation using an
external controller.

Section: X New Technology

Body System: 0 Nervous System
Operation: H Insertion
Body Part Approach Device/ Qualifier
Substance/
Technology
Q Vagus Nerve 3 Percutaneous R 8 New
Neurostimulator Technology
Lead with Paired Group 8
Stimulation
System

Vagus nerve stimulation (VNS) is a type of neuromodulation that

alters the activity of brain cells. Paired VNS therapy is used for stroke
rehabilitation following ischemic stroke to stimulate the motor cortex of
the brain when there are deficits in upper extremity motor function.

During implantation of the paired VNS system, a stimulator electrode

is wrapped around the left vagus nerve. The right vagus nerve is not

64 Fourth Quarter 2022 Coding Clinic

used because it is more likely to affect the activity of nerves of the
heart. A pocket is created in the subcutaneous tissue of the pectoral
region to hold the neurostimulator pulse generator. The electrode is
tunneled through subcutaneously to connect to the generator. When
activated, the device delivers electrical impulses along the vagus
nerve to the brainstem, where the charge reaches the cells of the
brain.

Once implanted, the patient undergoes traditional rehabilitation

therapy. A physical therapist triggers a wireless transmitter to send
a small burst of electrical stimulation to the vagus nerve while the
patient performs rehabilitative exercise to increase motor function.

The new code is specifically for the Vivistim® Paired VNS System.
Implantation of any other vagus nerve stimulator would be assigned
code 00HE3MZ Insertion of neurostimulator lead into cranial nerve,
percutaneous approach.

Computer-Assisted Transcranial Magnetic

Stimulation of the Prefrontal Cortex

New table X0Z, Other Procedures of Nervous System, was created

to report code X0Z0X18 Computer-assisted transcranial magnetic
stimulation of prefrontal cortex, new technology group 8, for
computer-assisted non-invasive magnetic stimulation of the prefrontal
cortex in the treatment of major depressive disorder in adult patients.

Section: X New Technology

Body System: 0 Nervous System
Operation: Z Other Procedures
Body Part Approach Device/Substance/ Qualifier
Technology
0 Prefrontal X External 1 Computer-assisted 8 New
Cortex Transcranial Technology
Magnetic Stimulation Group 8

A transcranial magnetic stimulation coil is placed against the scalp

to deliver magnetic pulses that stimulate nerve cells of a focal target
area of the dorsolateral prefrontal cortex. A region of the dorsolateral
prefrontal cortex has the strongest relationship with the subgenual

Coding Clinic Fourth Quarter 2022 65

cingulate, an area of the brain that when overactive, causes
symptoms of depression. Transcranial magnetic stimulation facilitates
dorsolateral prefrontal cortex control of the activity in the subgenual
cingulate and is optimal for neuromodulation.

Pressure-Controlled Intermittent Coronary

Sinus Occlusion

In table X2A, New Technology, Assistance of Cardiovascular System,

a new code was created to identify pressure-controlled intermittent
coronary sinus occlusion.

Body Part Approach Device/ Qualifier

Substance/
Technology
7 Coronary 3 Percutaneous 5 Intermittent 8 New
Sinus Coronary Sinus Technology
Occlusion Group 8

Pressure-controlled intermittent coronary sinus occlusion (PiCSO)

is an adjunct procedure performed with percutaneous coronary
intervention (PCI) following acute myocardial infarction (AMI).
While interventions, such as stenting and atherectomy address the
obstruction/infarct in the coronary arteries, PiCSO focuses on the
heart’s microvasculature by way of the venous system. The additional
treatment directed at microvasculature can contribute to reduction of
the infarct size and improvement in circulation within the heart muscle.

PiCSO begins by percutaneous insertion of a balloon catheter into

the femoral vein with placement at the ostium of the coronary sinus.
Pressure is increased intermittently via inflation and deflation of the
balloon to avoid complete blockage of circulation. The increase in
pressure via occlusion is an attempt to redistribute blood flow to the
damaged microvasculature and improve myocardial perfusion.

66 Fourth Quarter 2022 Coding Clinic

 Extracorporeal Histotripsy of Targeted Liver
Tissue Using Ultrasound-guided Cavitation

The root operation “Destruction” has been added to the body

system, Hepatobiliary System and Pancreas, to create a new table
XF5, Destruction of Hepatobiliary System and Pancreas, to capture
extracorporeal histotripsy of targeted liver tissue using ultrasound-
guided cavitation, as shown below.

Section: X New Technology

Body System: F Hepatobiliary System and Pancreas
Operation: 5 Destruction
Body Part Approach Device/ Qualifier
Substance/
Technology
0 Liver X External 0 Ultrasound- 8 New Technology
1 Liver, Right guided Group 8
Lobe Cavitation
2 Liver, Left Lobe

Histotripsy is a non-invasive, non-thermal ultrasound guided ablation

technology that uses a transducer to deliver acoustic energy in
short, high intensity pulses. The ultrasound waves form small
vacuum bubbles or cavities in liquid, known as cavitation. When the
bubbles can no longer absorb energy, they implode and destroy the
targeted tissue. This non-thermal, non-invasive ablation technique
uses ultrasound imaging to target and monitor the bubbles used in
cavitation.

Extracorporeal histotripsy of targeted liver tissue using ultrasound-

guided cavitation is an automated external beam ablative therapy
used to treat hepatocellular carcinoma.

Posterior Vertebral Body Tethering

The root operation “Supplement” has been added to the body system,
Muscles, Tendons, Bursae and Ligaments, to create a new table
XKU, Supplement of Muscles, Tendons, Bursae and Ligaments, to
capture posterior vertebral body tethering to augment the ligamentous
complex of the posterior spine.

Coding Clinic Fourth Quarter 2022 67

Section: X New Technology
Body System: K Muscles, Tendons, Bursae and Ligaments
Operation: U Supplement
Body Part Approach Device/ Qualifier
Substance/
Technology
C Upper Spine 0 Open 6 Posterior 8 New
Bursa and Ligament Vertebral Tether Technology
D Lower Spine Group 8
Bursa and Ligament

The posterior ligamentous complex is a structure that is comprised

of the facet joint capsule, ligamentum flavum and interspinous and
supraspinous ligaments. It stabilizes the vertebral column and restricts
hyperflexion by linking the posterior elements of the neighboring
vertebrae in fixed relation with each other. The posterior ligamentous
complex may be weakened by degeneration or compromised during
spinal fusion.

Posterior vertebral body tethering augments the posterior ligamentous

complex. A polyethylene terephthalate (PET) band is placed through
holes that are drilled in the uppermost spinous process and laced
side-to-side through holes in the other spinous processes. Another
band is threaded side-to-side through the contralateral holes in the
opposite direction. The bands are run through connectors that allow
the attachment of a rod to the vertebral body to create a rod-bone
connection without the use of pedicle screws and hooks. Tension
locks the bands within the connectors. The bands run under the
interspinous and supraspinous ligaments, which connect to the
spinous processes and reinforce the posterior ligamentous complex.

Posterior vertebral body tethering may be performed as an adjunct to

spinal fusion surgery to prevent the occurrence of proximal junctional
kyphosis. The provider may describe it as spinal tether, ligament
augmentation, ligament repair, and ligamentoplasty of the posterior
ligamentous complex. This procedure is different from vertebral body
tethering that is performed to straighten a scoliosis curve of the spine
as discussed in Coding Clinic, Fourth Quarter 2021, pages 51-52.
When vertebral body tethering is performed to exert pressure on the
vertebrae to correct a curvature, the root operation is Reposition.

68 Fourth Quarter 2022 Coding Clinic

 Internal Fixation Device with Tulip Connector

“Insertion” has been added to the body system, Bones, to create table
XNH, Insertion of Bones, to capture insertion of an internal fixation
device with tulip connector into the ilium for pelvic fixation and as an
adjunct to sacroiliac joint fusion for the treatment of spinal instabilities
or deformities.

Section: X New Technology

Body System: N Bones
Operation: H Insertion
Body Part Approach Device/ Qualifier
Substance/
Technology
6 Pelvic Bone, 0 Open 5 Internal 8 New
Right 3 Percutaneous Fixation Device Technology
7 Pelvic Bone, with Tulip Group 8
Left Connector

At table XRG, Fusion of Joints, body part values for E Sacroiliac Joint,
Right and F Sacroiliac Joint, Left were added with device value 5 for
Internal Fixation Device with Tulip Connector, to report sacroiliac joint
fusion for the treatment of spinal instabilities or deformities using a
sacroalar-iliac trajectory (into the sacrum, across the sacroiliac joint
and into the ilium).

Body Part Approach Device/ Qualifier

Substance/
Technology
E Sacroiliac 0 Open 5 Internal 8 New
Joint, Right 3 Percutaneous Fixation Device Technology
F Sacroiliac with Tulip Group 8
Joint, Left Connector

Coding Clinic Fourth Quarter 2022 69

 Insertion of Posterior Spinal Motion
Preservation Device

“Insertion” was added to the body system, Joints, to create table XRH,
Insertion of Joints, with codes to capture placement of posterior spinal
motion preservation devices, an alternative to spinal fusion designed
to maintain flexion, extension, lateral bending and axial rotation.

Section: X New Technology

Body System: R Joints
Operation: H Insertion
Body Part Approach Device/ Qualifier
Substance/
Technology
B Lumbar 0 Open 1 Posterior 8 New
Vertebral Joint Spinal Motion Technology
D Lumbosacral Preservation Group 8
Joint Device

Replacement of Synthetic Substitute

Meniscus of Knee

The root operation “Replacement” has been added to the body

system, Joints, to create codes in a new Table XRR, Replacement of
Joints, that capture replacement of the medial and lateral menisci of
the knee with synthetic substitute.

Section: X New Technology

Body System: R Joints
Operation: R Replacement
Body Part Approach Device / Substance Qualifier
/ Technology
G Knee, Joint, 0 Open L Synthetic 8 New
Right Substitute, Lateral Technology
H Knee Joint, Meniscus Group 8
Left M Synthetic
Substitute, Medial
Meniscus

70 Fourth Quarter 2022 Coding Clinic

This new technology is a less invasive procedure for those patients
with meniscal tears due to injury or degeneration. The development
of synthetic meniscal graft material addresses factors such as graft
availability and other issues that prevent the successful use of
allograft. In certain situations, a synthetic meniscal substitute may be
an alternative to knee arthroplasty in older individuals. The synthetic
device is placed between the femur and tibia and does not require
fixation to bone or soft tissues. The implant imitates the function of a
natural meniscus and redistributes loads across the knee joint.

Introduction of New Therapeutic Substances

Eleven new substance values were added to code Table XW0,

Introduction of Anatomical Regions, for the substances listed below.
Please note that all of the substances have a device, substance
technology value of 8 New Technology Group 8.

Device/Substance/Technology
0 Spesolimab Monoclonal Antibody
1 Daratumumab and Hyaluronidase-fihj
3 Maribavir Anti-infective
4 Teclistamab Antineoplastic
5 Mosunetuzumab Antineoplastic
6 Afamitresgene Autoleucel Immunotherapy
7 Tabelecleucel Immunotherapy
8 Treosulfan
9 Inebilizumab-cdon
D Engineered Allogeneic Thymus Tissue
X Broad Consortium Microbiota-based Live Biotherapeutic
Suspension

Spesolimab Monoclonal Antibody

New ICD-10-PCS codes have been created for the IV administration
of Spesolimab into the central or peripheral veins. Spesolimab is a
humanized anti-interleukin-36 receptor monoclonal antibody used
in the treatment of generalized pustular psoriasis (GPP). GPP is a
life-threatening skin condition caused by neutrophils accumulating
in the skin and characterized by episodes of widespread eruption
of pustules. Serious complications can result from flares of GPP
including heart failure, renal failure, sepsis and death. Spesolimab

Coding Clinic Fourth Quarter 2022 71

works by blocking the activation of the interleukin-36 (IL-36) receptor,
a signaling pathway in the immune system involved with autoimmune
diseases. Flares of GPP have been linked to the IL-36 pathway.

Daratumumab and Hyaluronidase-fihj

Daratumumab and hyaluronidase-fihj is administered via
subcutaneous injection and used in combination with other
medications to treat patients who are newly diagnosed with light chain
amyloidosis and patients with multiple myeloma. Light chain (AL)
amyloidosis is a life-threatening blood disorder where plasma cells
increase production of light chains. The light chains misfold and bind
together causing amyloid fibrils that can affect organs, most commonly
but not limited to the heart and kidneys. Other organ involvement
can include the liver and the gastrointestinal and nervous systems.
Daratumumab is a monoclonal antibody that works by targeting and
binding to the enzymatic protein CD38 on the surface of malignant
plasma cells that are responsible for the abnormal production of the
amyloid protein. Daratumumab destroys the malignant plasma cells
and/or directs the immune system to destroy them.

Maribavir Anti-infective
Maribavir is an anti-infective administered for cytomegalovirus (CMV)
infection in post-transplant patients with resistant/refractory infection.
Maribavir is an oral medication that works by inhibiting the pUL97
CMV enzyme, blocking virus replication. Three new ICD-10-PCS
codes were created to capture the oral and enteral administration of
Maribavir with the following body part and approach values: Mouth
and Pharynx/External, Upper GI/Via Natural or Artificial Opening and
Lower GI/Via Natural or Artificial Opening.

Teclistamab Antineoplastic
Teclistamab is a bispecific antibody, a type of immunotherapy, that
is used to treat relapsed or refractory multiple myeloma. Bispecific
antibodies work by binding to two sites with one molecule targeting
two distinct antigens. Teclistamab binds CD3 on T cells and the B cell
maturation antigen on myeloma cells. The result of the dual binding
triggers T cell activation in order to destroy myeloma cells. The
medication is administered as a subcutaneous injection.

Mosunetuzumab Antineoplastic
Mosunetuzumab antineoplastic is used to treat adults with relapsed
or refractory follicular lymphoma (R/R FL). Follicular lymphoma is
a slow-growing form of non-Hodgkin lymphoma where the body

72 Fourth Quarter 2022 Coding Clinic

makes abnormal B-lymphocytes. The term follicular refers to the fact
that the cancer cells are grouped in clusters, or follicles, within the
lymph nodes. While follicular lymphoma is slow growing, patients can
experience multiple relapses. Similar to Teclistamab, Mosunetuzumab
is a bispecific antibody that binds to CD3 on T cells and CD20
on B cells redirecting the T cells to eliminate malignant B cells.
Mosunetuzumab is administered intravenously, and ICD-10-PCS
codes were created to capture the administration in the central and
peripheral veins.

Afamitresgene Autoleucel Immunotherapy

Afamitresgene autoleucel immunotherapy is an autologous adoptive
cell transfer (ACT) therapy for treatment of synovial sarcoma (SyS)
and myxoid round cell liposarcoma (MRCLS). Synovial sarcoma is
a rare soft tissue sarcoma and, while it most commonly occurs in
the extremities, it can arise anywhere in the body. Myxoid round cell
liposarcoma is a rare liposarcoma that grows in the cells that store
fat and is generally located in the extremities. Afami-cel is comprised
of a patient’s T- cells, collected via leukapheresis and processed to
create a unique cancer treatment using the patient’s immune cells.
Following preconditioning of the patient’s immune system with the use
of chemotherapy, the processed T-cells are administered via a central
or peripheral vein. ICD-10-PCS codes have been created to capture
both body part values.

Tabelecleucel Immunotherapy
New ICD-10-PCS codes have been created for the IV administration
of tabelecleucel into the central and peripheral veins. Tabelecleucel
is an allogeneic Epstein-Barr virus (EBV)-specific T-cell
immunotherapy used in the treatment of rituximab-refractory Epstein-
Barr virus associated lymphoproliferative disorders (EBV-LPD).
Immunosuppressive medications taken post solid organ or allogeneic
hematopoietic cell transplants (HCL) can activate the EBV virus
that commonly infects 90% of the population. Normally the EBV
virus is controlled by the immune system, however, when taking
immunosuppressive medications, the EBV virus can be activated
and cause EBV-LPD, a rare and serious lymphoma. Tabelecleucel
is produced from T cells harvested from human donors who are
immune to EBV and manufactured with animal derived materials. The
manufactured cells recognize and bind to EBV-associated antigens on
EBV infected cells preventing the growth of EBV-associated cancer
cells.

Coding Clinic Fourth Quarter 2022 73

Treosulfan
New ICD-10-PCS codes have been created to capture the
administration of treosulfan via the central and peripheral veins.
Treosulfan is a bifunctional alkylating agent that may be used in
combination with fludarabine for conditioning prior to allogenic
hematopoietic stem cell transplantation (alloHSCT) to treat acute
myeloid leukemia (AML) and myelodysplastic syndrome (MDS) in
both children and adults. Treosulfan has a lower treatment-related
toxicity compared with other regimens.

Inebilizumab-cdon
New ICD-10-PCS codes have been created to capture the
administration of inebilizumab-cdon via the central and peripheral
veins. Inebilizumab-cdon is an anti-CD19 B-cell depleter for the
treatment of neuromyelitis optica spectrum disorder (NMOSD) in adult
patients who are anti-aquaporin-4 (AQP4) positive. NMOSD is an
autoimmune disorder where the immune system reacts against cells
in the central nervous system affecting mainly the optic nerves and
spinal cord and sometimes affects the brain.

Engineered Allogeneic Thymus Tissue

Engineered allogeneic thymus tissue has been approved for use in
patients with congenital athymia, a rare congenital disorder where
a child is born without a thymus. Donor-derived thymus tissue is
processed and implanted into the quadriceps muscle in one or both
legs in an open surgical procedure. The implanted allogenic thymus
regenerates the thymic function in these patients.

Broad Consortium Microbiota-Based Live Biotherapeutic

Suspension
A new code has been created for the rectal administration of
RBX2660. RBX2660 is a broad consortium microbiota-based live
biotherapeutic suspension used to treat recurrent C. difficile infection.
It is a non-antibiotic, live biotherapeutic, containing a broad group
of diverse spore and non-spore forming bacteria representing the
microbiome in a healthy human gut. The human-derived microbes
are taken from carefully screened donors to prevent transmissible
diseases or other pathogens from being passed on to the recipient.
The microbes go through a manufacturing process that includes
testing with quality control techniques resulting in a standardized
ready-to-use product. It is administered rectally from a pre-packaged,
single dose bag.

74 Fourth Quarter 2022 Coding Clinic

 Transfusion of New Therapeutic Substances

Effective October 1, 2022, new substance values were added to

code Table XW1, Transfusion of Anatomical Regions, for the four
substances listed below. This change results in eight new codes that
capture administration in the peripheral and central veins. Please note
all of the substances below have a qualifier of 8, New Technology
Group 8.

Body Part Approach Device/ Qualifier

Substance/
Technology
3 Peripheral 3 Percutaneous B 8 New
Vein Betibeglogene Technology
4 Central Vein Autotemcel Group 8
C Omidubicel
F OTL-103
G OTL-200

Betibeglogene Autotemcel
Betibeglogene autotemcel is an autologous hematopoietic stem cell
transplant-based ex vivo gene therapy for treatment of transfusion
dependent β-thalassemia. β-thalassemia is a genetic mutation of the
hemoglobin subunit beta (HBB) gene that results in a reduced level
of hemoglobin, decreased red blood cell production and anemia.
Betibeglogene autotemcel is a gene therapy that works by retrieving
the patient’s stem cells, engineering the cells and transplanting the
cells using a functioning version of the HBB gene into the patient’s
blood.

Omidubicel
Omidubicel is an advanced cell therapy for treatment of patients
with hematologic malignancies requiring allogeneic hematopoietic
stem cell transplant. Omidubicel is a proprietary, allogeneic stem cell
product that is manufactured from the ex vivo expansion of cord blood
with the goal of increasing the number of cells.

Coding Clinic Fourth Quarter 2022 75

OTL-103
OTL-103 is a genetically modified ex vivo autologous hematopoietic
stem/progenitor cell therapy used to treat Wiskott-Aldrich syndrome
(WAS). WAS is a genetic disorder caused by a mutation on an
X-chromosome. The mutation creates an inability to produce WAS
protein affecting different types of immune cells. OTL-103 engineers
the patient’s cells and a normal copy of the WAS gene is encoded
using a lentiviral vector and transfused into the patient.

OTL-200
OTL-200 is a genetically modified ex vivo autologous hematopoietic
stem/progenitor cell therapy used to treat metachromatic
leukodystrophy (MLD). MLD is a genetic neurodegenerative disorder
caused by mutations in the arylsulfatase A (ARSA) gene leading
to neurological damage. OTL-200 modifies the patient’s stem cells
to replace the defective ARSA gene with a functional gene using a
lentiviral vector and infusing the genetically modified cells back into
the patient.

Computer-Aided Analysis for the Detection

and Classification of Epileptic Events

Code XXE0X48, Measurement of brain electrical activity,

computer-aided semiologic analysis, new technology group
8, has been created in Section X Table XXE, Measurement of
Physiological Systems, to identify the analysis of epilepsy associated
events. The analysis includes semiologic data such as velocity and
acceleration of movements, seizure frequency, duration, heart and
respiratory rates, using artificial intelligence software to aid in the
detection and classification of epileptic events, as shown below.

Body Part Approach Device/Substance/ Qualifier

Technology
0 Central X External 4 Brain Electrical 8 New
Nervous Activity, Computer-aided Technology
Semiologic Analysis Group 8

76 Fourth Quarter 2022 Coding Clinic

 Quantitative Flow Rate for Noninvasive Analysis
of Coronary Angiography

Code XXE3X58, Measurement of coronary artery flow,

quantitative flow ratio analysis, new technology group 8, was
created in table XXE, to describe a noninvasive assessment of
coronary vessels that applies an advanced three-dimensional (3-D)
mathematical modeling of angiographic images. Quantitative flow rate
values may be calculated based on the 3-D image of the anatomy and
flow velocity to facilitate coronary catheterization and percutaneous
coronary intervention.

Body Part Approach Device/ Qualifier

Substance/
Technology
3 Arterial X External 5 Coronary Artery 8 New Technology
Flow, Quantitative Group 8
Flow Ratio Analysis

Simulation for Assessment of Coronary

Obstruction Risk

Code XXE3X68, Measurement of coronary artery flow, computer-

aided valve modeling and notification, new technology group 8,
was created in table XXE to identify the use of simulation software to
assess the risk of coronary obstruction in patients with severe aortic
valve stenosis.

Body Part Approach Device/ Qualifier

Substance/
Technology
3 Arterial X External 6 Coronary Artery 8 New Technology
Flow, Computer- Group 8
aided Valve
Modeling and
Notification

Coding Clinic Fourth Quarter 2022 77

 Gene Expression Assay

Code XXE5X38, Measurement of infection, whole blood reverse

transcription and quantitative real-time polymerase chain
reaction, new technology group 8, has been created in Section X
Table XXE, Measurement of Physiological Systems, to identify the
gene expression assay measurement of prevalent genes in a blood
specimen that correlates to a response to systemic infection and
indicates the likelihood of infection-positive systemic inflammation.

Body Part Approach Device/ Qualifier

Substance/
Technology
5 Circulatory X External 3 Infection, Whole 8 New Technology
Blood Reverse Group 8
Transcription and
Quantitative Real-
time Polymerase
Chain Reaction

Extracorporeal Antimicrobial Administration

During Renal Replacement Therapy

A code has been created in Section X, Table XY0, Extracorporeal

Introduction with a new substance value 2 Taurolidine Anti-infective
and Heparin Anticoagulant, to identify the instillation of taurolidine
and heparin when administered during renal replacement therapy to
reduce the risk of catheter-related blood stream infection (CRBSI).
Facilities can continue to report the renal replacement therapy
(RRT) using the appropriate code from Table 5A1, Extracorporeal
or Systemic Assistance and Performance, Physiological Systems,
Performance.

Body Part Approach Device/Substance/ Qualifier

Technology
Y Extracorporeal X External 2 Taurolidine Anti- 8 New
infective and Heparin Technology
Anticoagulant Group 8

78 Fourth Quarter 2022 Coding Clinic

 Changes to the ICD-10-CM Official
Guidelines for Coding and Reporting
A summary of the modifications to the ICD-10-CM Official Guidelines
for Coding and Reporting are included below. The complete guidelines
may be downloaded by visiting https://www.cdc.gov/nchs/icd/
Comprehensive-Listing-of-ICD-10-CM-Files.htm

The modifications are published below using the following format:

Narrative changes appear in bold text (e.g., severe sepsis)
Items underlined were moved within the guidelines since October
1, 2021 (e.g., severe sepsis)
Deletions are shown as strikeouts (e.g., severe sepsis)

Section I. Conventions, general coding guidelines and chapter

specific guidelines

A. Conventions for the ICD-10-CM …

19. Code assignment and Clinical Criteria

The assignment of a diagnosis code is based on the
provider’s diagnostic statement that the condition exists.
The provider’s statement that the patient has a particular
condition is sufficient. Code assignment is not based
on clinical criteria used by the provider to establish
the diagnosis. If there is conflicting medical record
documentation, query the provider.

B. General Coding Guidelines …

14. Documentation by Clinicians Other than the Patient’s

Provider…
There are a few exceptions when code assignment may
be based on medical record documentation from clinicians
who are not the patient’s provider (i.e., physician or other
qualified healthcare practitioner legally accountable for
establishing the patient’s diagnosis). In this context,
“clinicians” other than the patient’s provider refer to
healthcare professionals permitted, based on regulatory or
accreditation requirements or internal hospital policies, to
document in a patient’s official medical record.

Coding Clinic Fourth Quarter 2022 79

 These exceptions include codes for:

• Underimmunization status
The BMI, coma scale, NIHSS, blood alcohol level
codes, codes for social determinants of health and
underimmunization status should only be reported as
secondary diagnoses.

See Section I.C.21.c.17. for additional information

regarding coding social determinants of health.

16. Documentation of Complications of Care

There must be a cause-and-effect relationship between the
care provided and the condition, and the documentation
must support that the condition is clinically significant.
It is not necessary for the provider to explicitly
document the term “complication.” For example,
if the condition alters the course of the surgery as
documented in the operative report, then it would be
appropriate to report a complication code. Query the
provider for clarification if the documentation is not clear
as to the relationship between the condition and the
care or procedure.

C. Chapter Specific Coding Guidelines . . .

Chapter 1: Certain Infectious and Parasitic Diseases

(A00-B99), U07.1, U09.9 . . .

a. Human Immunodeficiency Virus (HIV) Infections . . .

2) Selection and sequencing of HIV codes . . .

(a) Patient admitted for HIV-related condition

An exception to this guideline is if the reason
for admission is hemolytic-uremic syndrome
associated with HIV disease. Assign code
D59.31, Infection-associated hemolytic-uremic
syndrome, followed by code B20, Human
immunodeficiency virus [HIV] disease.

80 Fourth Quarter 2022 Coding Clinic

 (i) HIV managed by antiretroviral medication
If a patient with documented HIV disease, HIV-
related illness or AIDS is currently managed on
antiretroviral medications, assign code B20, Human
immunodeficiency virus [HIV] disease.

d. Sepsis, Severe Sepsis, and Septic Shock Infections

resistant to antibiotics . . .

3) Sequencing of severe sepsis

For infection-associated hemolytic-uremic syndrome

with severe sepsis, see guideline I.C.1.d.9.

9) Hemolytic-uremic syndrome associated with

sepsis
If the reason for admission is hemolytic-uremic
syndrome that is associated with sepsis, assign
code D59.31, Infection-associated hemolytic-
uremic syndrome, as the principal diagnosis.
Codes for the underlying systemic infection and
any other conditions (such as severe sepsis)
should be assigned as secondary diagnoses.

g. Coronavirus infections …

1) COVID-19 infection (infection due to SARS-CoV-2)

(n) Underimmunization for COVID-19 Status

See Section I.B.14. for immunization documentation

by clinicians other than patient’s provider.

2. Chapter 2: Neoplasms (C00-D49) . . .

General Guidelines …

a. Admission/Encounter for treatment of primary site
If the malignancy is chiefly responsible for
occasioning the patient admission/encounter and
treatment is directed at the primary site, designate
the primary malignancy as the principal/first-listed
diagnosis.

Coding Clinic Fourth Quarter 2022 81

 The only exception to this guideline is if the
administration of chemotherapy, immunotherapy or
external beam radiation therapy is chiefly responsible
for occasioning the admission/encounter. In that
case, assign the appropriate Z51.-- code as the first-
listed or principal diagnosis, and the underlying
diagnosis or problem for which the service is being
performed as a secondary diagnosis.

t. Secondary malignant neoplasm of lymphoid tissue

When a malignant neoplasm of lymphoid tissue
metastasizes beyond the lymph nodes, a code from
categories C81-C85 with a final character “9” should
be assigned identifying “extranodal and solid organ
sites” rather than a code for the secondary neoplasm
of the affected solid organ. For example, for
metastasis of B-cell lymphoma to the lung, brain and
left adrenal gland, assign code C83.39, Diffuse large
B-cell lymphoma, extranodal and solid organ sites.

Chapter 4: Endocrine, Nutritional, and Metabolic Diseases

(E00-E89) …

a. Diabetes mellitus …

3) Diabetes mellitus and the use of insulin, oral

hypoglycemics, and injectable non-insulin drugs…

If the patient is treated with both oral hypoglycemic

drugs and insulin, both code Z79.4, Long term
(current) use of insulin, and code Z79.84, Long term
(current) use of oral hypoglycemic drugs, should be
assigned.

If the patient is treated with both insulin and an

injectable non-insulin antidiabetic drug, assign codes
Z79.4, Long term (current) use of insulin, and Z79.85,
Long-term (current) use of injectable non-insulin
antidiabetic drugs.

82 Fourth Quarter 2022 Coding Clinic

 If the patient is treated with both oral hypoglycemic
drugs and an injectable non-insulin antidiabetic drug,
assign codes Z79.84, Long term (current) use of
oral hypoglycemic drugs, and Z79.85, Long-term
(current) use of injectable non-insulin antidiabetic
drugs.

6) Secondary diabetes mellitus …

(a) Secondary diabetes mellitus and the use of

insulin, oral hypoglycemic drugs, or injectable
non-insulin drugs

If the patient is treated with both oral

hypoglycemic drugs and insulin, both code
Z79.4, Long term (current) use of insulin, and
code Z79.84, Long term (current) use of oral
hypoglycemic drugs, should be assigned.

If the patient is treated with both insulin and

an injectable non- insulin antidiabetic drug,
assign codes Z79.4, Long- term (current) use of
insulin, and Z79.85, Long-term (current) use of
injectable non-insulin antidiabetic drugs.

If the patient is treated with both oral hypoglycemic

drugs and an injectable non-insulin antidiabetic
drug, assign codes Z79.84, Long-term (current)
use of oral hypoglycemic drugs, and Z79.85, Long-
term (current) use of injectable non-insulin
antidiabetic drugs.

Chapter 5: Mental, Behavioral and Neurodevelopmental

disorders (F01 – F99)

b. Mental and behavioral disorders due to

psychoactive substance use

1) In Remission
Selection of codes describing “in remission” for
categories F10-F19, Mental and behavioral disorders
due to psychoactive substance use (categories

Coding Clinic Fourth Quarter 2022 83

 F10-F19 with -.11, -.21, -.91) requires the provider’s
clinical judgment and are assigned only on the
basis of provider documentation (as defined in the
Official Guidelines for Coding and Reporting), unless
otherwise instructed by the classification.

5) Blood Alcohol Level

See Section I.B.14. for blood alcohol level

documentation by clinicians other than patient’s
provider.

d. Dementia

The ICD-10-CM classifies dementia (categories

F01, F02, and F03) on the basis of the etiology
and severity (unspecified, mild, moderate or
severe). Selection of the appropriate severity
level requires the provider’s clinical judgment and
codes should be assigned only on the basis of
provider documentation (as defined in the Official
Guidelines for Coding and Reporting), unless
otherwise instructed by the classification. If the
documentation does not provide information about
the severity of the dementia, assign the appropriate
code for unspecified severity.

If a patient is admitted to an inpatient acute care

hospital or other inpatient facility setting with
dementia at one severity level and it progresses
to a higher severity level, assign one code for the
highest severity level reported during the stay.

15. Chapter 15: Pregnancy, Childbirth, and the Puerperium

(O00-O9A) …

a. General Rules for Obstetric Cases …

7) Completed weeks of gestation

In ICD-10-CM, “completed” weeks of gestation
refers to full weeks. For example, if the provider
documents gestation at 39 weeks and 6 days,

84 Fourth Quarter 2022 Coding Clinic

 the code for 39 weeks of gestation should be
assigned, as the patient has not yet reached 40
completed weeks.

i. Gestational (pregnancy induced) diabetes

Codes Z79.4, Long-term (current) use of insulin, Z79.84,

Long-term (current) use of oral hypoglycemic drugs, and
Z79.85, Long-term (current) use of injectable non-
insulin antidiabetic drugs, should not be assigned with
codes from subcategory O24.4.

q. Termination of Pregnancy and Spontaneous

abortions

4) Hemorrhage following elective abortion

For hemorrhage post elective abortion, assign
code O04.6, Delayed or excessive hemorrhage
following (induced) termination of pregnancy.
Do not assign code O72.1, Other immediate
postpartum hemorrhage, as this code should
not be assigned for post abortion conditions. Do
not assign code Z33.2, Encounter for elective
termination of pregnancy, when the patient
experiences a complication post elective abortion.

16. Chapter 16: Certain Conditions Originating in the

Perinatal Period (P00-P96) …

b. Observation and Evaluation of Newborns for

Suspected Conditions not Found . . .

1) Use of Z05 codes

Assign a code from category Z05, Observation and
evaluation of newborn for suspected diseases and
conditions ruled out, to identify those instances when
a healthy newborn is evaluated for a suspected
condition/disease that is determined after study not
to be present. Do not use a code from category Z05
when the patient is documented to have signs or
symptoms of a suspected problem; in such cases
code the sign or symptom.

Coding Clinic Fourth Quarter 2022 85

 19. Chapter 19: Injury, poisoning, and other certain other
consequences of external causes (S00-T88) . . .

e. Adverse Effects, Poisoning, Underdosing and Toxic

Effects …

5) The occurrence of drug toxicity is classified in

ICD-10-CM as follows:

(c) Underdosing

Underdosing refers to taking less of a medication

than is prescribed by a provider or a manufacturer’s
instruction. Discontinuing the use of a prescribed
medication on the patient’s own initiative (not
directed by the patient’s provider) is also classified
as an underdosing. For underdosing, assign
the code from categories T36-T50 (fifth or sixth
character “6”). Documentation of a change in the
patient’s condition is not required in order to
assign an underdosing code. Documentation
that the patient is taking less of a medication
than is prescribed or discontinued the
prescribed medication is sufficient for code
assignment.

21. Chapter 21: Factors influencing health status and

contact with health services (Z00-Z99) . . .

c. Categories of Z Codes . . .

3) Status …

Z28.3 Underimmunization status . . .

See Section I.B.14. for underimmunization

documentation by clinicians other than the
patient’s provider.

86 Fourth Quarter 2022 Coding Clinic

 10) Counseling

Z71 Persons encountering health services for other

counseling and medical advice, not elsewhere
classified

Code Z71.87, Encounter for pediatric-to-

adult transition counseling, should be
assigned when pediatric-to-adult transition
counseling is the sole reason for the
encounter or when this counseling is
provided in addition to other services, such
as treatment of a chronic condition. If both
transition counseling and treatment of a
medical condition are provided during the
same encounter, the code(s) for the medical
condition(s) treated and code Z71.87 should
be assigned, with sequencing depending on
the circumstances of the encounter.

14) Miscellaneous Z Codes

Z73 Problems related to life management difficulty

Note: These codes should be assigned only

when the documentation specifies that the
patient has an associated problem.

17) Social Determinants of Health

Codes describing problems or risk factors related to social

determinants of health (SDOH) should be assigned when this
information is documented. Assign as many SDOH codes as
are necessary to describe all of the problems or risk factors.
These codes should be assigned only when the documentation
specifies that the patient has an associated problem or risk
factor. For example, not every individual living alone would be
assigned code Z60.2, Problems related to living alone.
 

Coding Clinic Fourth Quarter 2022 87

 Changes to the ICD-10-PCS Official
Guidelines for Coding and Reporting
A summary of the modifications to the ICD-10-PCS Official Guidelines
for Coding and Reporting is included below. The complete guidelines
may be downloaded by visiting https://www.cms.gov/medicare/icd-
10/2022-icd-10-pcs.

The modifications are published below using the following format:

Narrative changes appear in bold text (e.g., more definitive root

operation).

Items underlined were moved within the guidelines since October

1, 2022 (e.g., control of acute bleeding). Deletions are shown as
strikeouts (e.g., any of the definitive root operations).

Medical and Surgical Section Guidelines (section 0)

B3. Root Operation

Detachment procedures of extremities

B3.19
The root operation Detachment contains qualifiers that can be
used to specify the level where the extremity was amputated.
These qualifiers are dependent on the body part value in the
“upper extremities” and “lower extremities” body systems. For
procedures involving the detachment of all or part of the upper
or lower extremities, the procedure is coded to the body part
value that describes the site of the detachment.

Example: An amputation at the proximal portion of the shaft of

the tibia and fibula is coded to the Lower leg body part value in
the body system Anatomical Regions, Lower Extremities, and
the qualifier High is used to specify the level where the extremity
was detached.

The following definitions were developed for the Detachment

qualifiers:

88 Fourth Quarter 2022 Coding Clinic

Body Part Qualifier Definition
Upper 1 High: Amputation at the proximal
arm and portion of the shaft of the humerus or
upper leg femur
2 Mid: Amputation at the middle portion of
the shaft of the humerus or femur
3 Low: Amputation at the distal portion of
the shaft of the humerus or femur
Lower 1 High: Amputation at the proximal
arm and portion of the shaft of the radius/ulna or
lower leg tibia/fibula
2 Mid: Amputation at the middle portion of
the shaft of the radius/ulna or tibia/fibula
3 Low: Amputation at the distal portion of
the shaft of the radius/ulna or tibia/fibula
Hand and 0 Complete*
Foot
4 Complete 1st Ray
5 Complete 2nd Ray
6 Complete 3rd Ray
7 Complete 4th Ray
8 Complete 5th Ray
9 Partial 1st Ray
B Partial 2nd Ray
C Partial 3rd Ray
D Partial 4th Ray
F Partial 5th Ray
Thumb, 0 Complete: Amputation at the
finger, or metacarpophalangeal/metatarsal-
toe phalangeal joint
1 High: Amputation anywhere along the
proximal phalanx
2 Mid: Amputation through the proximal
interphalangeal joint or anywhere along
the middle phalanx
3 Low: Amputation through the distal
interphalangeal joint or anywhere along
the distal phalanx

Coding Clinic Fourth Quarter 2022 89

*When coding amputation of Hand and Foot, the following
definitions are followed:

• Complete: Amputation through the carpometacarpal joint

of the hand, or through the tarsal-metatarsal joint of the foot.
• Partial: Amputation anywhere along the shaft or head of
the metacarpal bone of the hand, or of the metatarsal bone of
the foot.

B4. Body Part

B4.1c
If a single vascular procedure is performed on a continuous section
of an arterial or venous body part, code the body part value
corresponding to the anatomically most proximal (closest to the heart)
portion of the arterial or venous body part.

B6. Device

General guidelines
B6.1a
A device is coded only if a device remains after the procedure is
completed. If no device remains, the device value No Device is coded.
In limited root operations, the classification provides the qualifier
values Temporary and Intraoperative, for specific procedures involving
clinically significant devices, where the purpose of the device is to be
utilized for a brief duration during the procedure or current inpatient
stay. If a device that is intended to remain after the procedure is
completed requires removal before the end of the operative episode in
which it was inserted (for example, the device size is inadequate or an
event documented as a complication occurs), both the insertion and
removal of the device should be coded.

90 Fourth Quarter 2022 Coding Clinic