Performance Measurement Network

Question: Failed attempt at thrombectomy

I have a question regarding a failed attempt at a thrombectomy (Attempted mechanical thrombectomy of M1 occlusion, s/p unsuccessful mechanical thrombectomy. Procedure terminated after multiple attempts at clot. The M1 segment remained occluded with no recanalization.

According to coding instructions we are to count those cases that were attempted but failed. My issue is this attempted/failed case did not have the thrombectomy attempt coded. I sent a note to our coders and was informed when a procedure is unsuccessful they code it to the root operation that was completed, in this case the dilation. Had no dilation been done and they only attempted the(thrombectomy extirpation they would have coded it to an inspection. Either way, they would not code the extirpation if it was not successful. That being said if we do not enter that procedure code it will not allow us to answer the questions pertaining to the thrombectomy. I did not want to enter a code for a procedure that was not coded in the medical record. Can you please advise how we should handle these cases for abstraction of the thrombectomy questions and entry in to the database. Thank you for your help on this issue.

Answer:

There is no way in either ICD-10-CM or ICD-10-PCS to code a failed procedure. In the event of an unsuccessful thrombectomy, i.e. meaning that the extirpation procedure was not performed, it is possible for the coder to select a code associated with the root procedure accomplished.

There is a procedure coding guideline B3.3 that states: "If a procedure is discontinued before any other root operation is performed, code the root operation for the body part or anatomical region."

Regarding data abstraction for CSTK-08 Thrombolysis in Cerebral Infarction (TICI) measure, please include only those cases assigned an ICD-10-PCS principal or other procedure code as detailed in Appendix A, Table 8.1a Thrombolytic Therapy or Table 8.1b Mechanical Reperfusion Therapy in the denominator population.

Thank you.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: CSTK-08, CSTK 08-Thrombectomy
Manual: Current Manual (current data collection period; prior to data transmission)
File:

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