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Resolved Complication VP shunt

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LindaS_62015

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When the physician says that the patient has a "Malfunctioning VP shunt" as his diagnosis how should this be coded? Per the record the VP sunt was damaged during a mastectomy on a previous encounter. The ventricular portion of the shunt was previously removed. The patient comes in now with cellulitis of the neck and a protruding tube 10cm coming out of her neck. The patient pulled some of the shunt out before coming to the ED. Even though the physician documents VP shunt Malfunctioning...is this still considered a VP shunt complication, or retained device/foriegn body? The remaining portion of the shunt was removed during this encounter. The surgeon said that the shunt was removed by pulling on the tube in the chest and 25 cm was removed from the peritoneal cavity. A separate incision was made in the left neck and a portion of tube was removed from the subcutaneous tissue. What PCS codes should be assigned? I have PCS codes 0WPGX0Z, 0JPS00Z but want to see if I'm on the right track. Thank you, Linda
 
I would consider this both. If the provider stated it was a malfunction you can go with that. However, they may not know that the other code is available, retained device.

Another thing to note was if the device was supposed to have some left in. Then it is not retained. Sounds like that is what happened. Ultimately, if I had to pick /s being able to query, I would go with malfunction. It is always about intent.
 
0WPGX0Z - Removal of Drainage Device from Peritoneal Cavity, External Approach
0JPS00Z - Removal of Drainage Device from Head and Neck Subcutaneous Tissue and Fascia, Open Approach
Yes, you can use both of these codes as they pulled the chest one and also did a procedure to remove the neck. Normally you would not have to use both. But the tube was in two parts.
A separate incision was made in the left neck and a portion of tube was removed from the subcutaneous tissue. What PCS codes should be assigned? I have PCS codes 0WPGX0Z, 0JPS00Z but want to see if I'm on the right track. Thank you, Linda
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