Item 43e. PDA Ligation or PDA Closure by Catherization
Q: I am getting an error notice when I add surgery codes for PDA Ligation or PDA Closure by Catheterization.
A: If a closure of the ductus arteriosus by ligation or catheterization was performed, code at least one of the following three surgery codes should be present:
- S515 Open thoracotomy for patent ductus arteriosus closure
- S516 Thoracoscopic surgery for patent ductus arteriosus closure
- S605 Interventional catheterization for patent ductus arteriosus closure
If an infant had PDA repair as part of other heart surgery, PDA surgery should be coded as Yes, and a specific surgical code for PDA Surgery (S515, S516, S605) as well as any codes related to the other heart surgery should be entered. For example, if the PDA ligated as a component of the repair or palliation of congenital heart disease, use a specific surgical code for PDA surgery (S515, S516, S605) and code S504.
Item 46a. Retinopathy of Prematurity
Q: Would Avastin treatment for ROP be considered as surgery?
A: No. Avastin is a drug and therefore would not be considered as surgery.
Item 47a. Other Surgery
Q: Would a removal of a percutaneous gastrostomy or jejunostomy tube count as surgery?
A: Only if the removal was done under general or spinal anesthesia.
Q: Would a broviac placement count as surgery?
A: Central lines or line placement is not considered surgery even if performed under general or spinal anesthesia.
Q: What surgery code should we use for esophageal dilations?
A: S211 if esophagoscopy (with or without biopsy) was performed. S200 if the procedure was done under general or spinal anesthesia.
Q: What surgery code should we use for coarctation repair?
A: S504 Repair or palliation of congenital heart disease.
Q: Why so much detail on the GI surgeries and so little on the cardiacs?
A: The number of different cardiac procedures is so large that we went for the simplest solution. However, we do have information on the congenital defect from the birth defect codes so that these can be linked.
Q: S503, what do you want coded under a major vascular injury surgery?
A: The use of “injury” suggests the code should be used for repair of iatrogenic injuries of major vessels not for repair of birth defects.
Item 47a. Surgical complications
Q: If a patient experiences surgical complication from a procedure not listed in Appendix D (Other Surgery), should I still record it?