1. Cardiovascular Systems Chapter 10 1

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3. Objectives Master anatomical concepts necessary to understand the cardiovascular system Define key terms, and recognize common eponyms and acronyms Explain the most common pathologies that effect this system Understand cardiovascular procedures and surgeries, and where in CPT® to locate the relevant codes Introduce ICD-9-CM and HCPCS Level II codes and coding guidelines as they apply to this system Supply examples and review material to improve your application of the above concepts 12/7/20153

4. Circulatory System Cardiovascular System –Heart –Blood Vessels Arteries Veins Lymphatic System 12/7/20154

6. Anatomy Arteries –Carry oxygenated blood – Take blood away from heart to the body Veins –Carry deoxygenated blood –Bring blood back to the heart from the capillary beds Capillaries –Connect arteries and veins 12/7/20156

7. Anatomy Lymphatic System –Lymph – fluid collected –Lymph nodes – small collections of lymphatic tissue through which lymph fluid is filtered –Lymphocytes – cells of the immune system 12/7/20157

8. Electrical Conduction in the Heart –Conduction begins in sinoatrial node of right atrium Nature’s pacemaker Firing causes contraction of muscle –Moves to atrioventricular node Then to Bundle of His along septum Then to Purkinje fibers along the surface of ventricles

9. Circulations Pulmonary Circulation –Pushes deoxygenated blood into the lungs –Carbon dioxide removed and oxygen added –Blood flows to the left atrium Systemic Circulation –Blood flows from left atrium into the left ventricle –Pumped to the body to deliver oxygen and remove carbon dioxide 12/7/20159

10. Heart 4 Chambers –Two atria –Two ventricles Three layers –Myocardium –Epicardium –Pericardium 12/7/201510

11. Heart Valves Atrioventricular valves –Tricuspid –Bicuspid Semilunar valves –Pulmonary –Aortic 12/7/201511

12. ICD-9-CM Coding Chapter 01 – Infectious and parasitic diseases Chapter 02 – Neoplasms Chapter 07 – Diseases of the Circulatory System Chapter 14 – Congenital Anomalies Chapter 16 – Signs, Symptoms and Ill- Deffined Conditions 12/7/201512

13. Diseases of the Circulatory System Acute rheumatic fever (390-392) –Symptoms include fever, joint pain, lesions of the heart, blood vessels and joint connective tissue, abdominal pain, skin changes, and chorea Chronic rheumatic heart disease (393- 398) –Persistant inflammation of heart lining due to rheumatic heart disease.

14. ICD-9-CM: Hypertension Hypertensive Disease –401 Essential hypertension –402 Hypertensive heart disease –403 Hypertensive chronic kidney disease –404 Hypertensive heart and chronic kidney disease

15. ICD-9-CM: Ischemic Heart Disease 410 Acute myocardial infarction 411 Other acute and subacute forms of ischemic heart disease 412 Old myocardial infarction 413 Angina pectoris 414 Other forms of chronic ischemic heart disease

16. ICD-9-CM: Aneurysm 414.1 Aneurysm and dissection of heart –414.10 Aneurysm of heart (wall) –414.11 Aneurysm of coronary vessels –414.12 Dissection of coronary artery –414.19 Other aneurysm of heart

17. ICD-9-CM: Heart Disease 415 – 417 Diseases of pulmonary circulation 420 Acute pericarditis 421 Acute and subacute endocarditis 422 Acute myocarditis 423 Other diseases of pericardium 424 Other diseases of endocardium 425 Cardiomyopathy 426 Conduction disorders 427 Cardiac dysrhythmias 428 Heart Failure 429 Ill-defined descriptions and complications of heart disease

18. ICD-9-CM: Congenital Anomalies 745 Bulbus cordis anomalies and anomalies of cardiac septal closure 746 Other congenital anomalies of heart 747 Other congenital anomalies of circulatory system

19. Signs & Symptoms 785 Symptoms involving cardiovascular system –785.0 Tachycardia, unspecified –785.1 Palpitations –785.2 Undiagnosed cardiac murmurs –785.3 Other abnormal heart sounds –785.4 Gangrene –785.5X Shock without mention of trauma –785.6 Enlargement of lymph nodes –785.9 Other symptoms involving cardiovascular system 786.5X Chest pain –786.50 Chest pain, unspecified –786.51 Precordial pain –786.59 Other

20. Terms Apex – bottom point of the heart Retrograde – against the current Antegrade – with the current Cardioversion – shock treatment to the heart CPR – Cardiopulmonary resuscitation Tachycardia – rapid beating of the heart Pacing – refers to electrical activity of the heart 12/7/201520

21. CPT Coding Surgical Section – 33010-37799 Radiology Section –Heart – 75557-75574 –Vascular – 75600 – 75989 –Diagnostic Ultrasound (various CPTs) –Radiologic Guidance – 77001 – 77032 –Nuclear Medicine – 78414 – 78499 Medicine Section –Cardiovascular – 92950 – 93799 –Noninvasive Vascular Diagnostic Studies – 93875-93990

22. Pericardium Pericardiocentesis (33010 – 33011) –Diagnostic test –Cardiac tamponade –Radiological supervision and interpretation (76930) Pericardial window (33025)

23. Pacemakers/Defibrillators (33202- 33249) Pacemaker System Pacing cardioverter-defibrillator system Codes –Insertion or replacement (33210-33213) –Implanted pacemakers (33212-33214) –Biventricular (2 ventricles) (33224-33226)

24. Electrophysiologic Operative Procedures Incision –33250 – 33261 Endoscopy –33265 - 33266

25. Wounds of the Heart and Great Vessels 33300-33335 – repair of great vessels Great vessels: –Superior vena cava –Inferior vena cava –Pulmonary artery –Four pulmonary veins –Aorta 12/7/201525

26. Cardiac Valve Procedures Aortic Valve (33400 – 33417) Mitral Valve (33420 – 33430) Tricuspid Valve (33460 – 33468) Pulmonary Valve (33470 – 33478)

27. CABG Coronary Artery Bypass Graft –Venous (33510-33516) –Arterial-Venous (33517-33523) –Reoperation (+33530) –Arterial (33533-33536) –Arterial Graft (33548)

28. Cardiac Anomalies (33600-33853) Single Ventricle and Other Complex Cardiac Anomalies (33600 – 33622) Septal Defect (33641 – 33697) Sinus of Valsalva (33702 – 33722) Venous Anomalies (33724 – 33732) Shunting Procedures (33735 – 33768) Transposition of the Great Vessels (33770 – 33783) Truncus Arteriosus (33786 – 33788) Aortic Anomalies (33800 – 33853)

29. Heart/Lung Transplantation 33930-33945 Distinct Components of Physician Work –Cadaver donor cardiectomy with or without pneumonectomy –Backbench work –Recipient heart with or without lung allotransplantation 12/7/201529

30. Aneurysms Abdominal Aorta Axillary artery Basilar Artery Brachial Artery Carotid Artery Celiac Artery Femoral Artery Hepatic Artery Iliac Artery Innominate Artery Intracranial Artery Mesenteric Artery Popliteal Artery Radial Artery Renal Artery Splenic Artery Subclavian Artery Thoracoabdominal Aortal Ulnar Artery Vertebral Artery

31. Thromboendarterectomy/Angioplasty Clots –Removed endoscopically Plaque –Removed endoscopically –Balloon angioplasty –Stents

32. Bypass Grafts Non-coronary vessels –Vein (35500-35572) –In-situ vein (35583-35671) Vein is left in native location –Other than vein (35681-35683) Code by type/location 12/7/201532

33. Vascular Injection Procedures Treatment of aneurysm Injection for venography and visualization Diagnostic 12/7/201533

34. Central Venous Access (36555-36598) Placed for frequent access to bloodstream Tip of catheter must terminate in the: –Subclavian –Brachiocephalic –Iliac –Inferior or superior vena cava Code by –Procedure (insertion, repair, replacement, removal, etc.) –Tunneled or not –With pump or port –Patient age See CVAP table in CPT® 12/7/201534

35. CPT® Hemodialysis (36800-36822) Portal Decompression (37410-37183) –Treat hypertension/occlusion of portal vein –TIPS (37182, 37183) diverts blood from the portal vein to the hepatic vein Transcatheter Procedures –Removal of clot Arterial (37184-37186) Venous (37187-37188) Other (37195-37216) Foreign body retrieval, stent placement, etc. 12/7/201535

36. Endovascular Revascularization (37220- 37235) Treat occlusive disease in lower extremities Three territories –Illiac –Femoral/Popliteal –Tibial/Peroneal Codes arranged in a hierarchy for each territory –stent placement with atherectomy (highest) –stent placement –atherectomy –angioplasty (lowest) – 12/7/201536

37. Bundled to Endovascular Revascularization (37220-37235) –conscious sedation –vascular access –catheter placement –traversing the lesion –imaging related to the intervention (previously billed as the supervision and interpretation code for the specific intervention) –use of an embolic protection device (EPD) –imaging for closure device placement –closure of the access site 37

38. Medicine Section Therapeutic services and procedures Cardiography Cardiovascular monitoring services Implantable wearable cardiac device evaluations Echocardiography Cardiac Catheterizations Intracardiac Electrophysiological Procedures/Studies Peripheral Arterial Disease Rehabilitation Noninvasive physiologic studies and procedures Other procedures 12/7/201538

39. CPR Cardiopulmonary resuscitation –Includes defibrillation –Includes treatment to the pulmonary system –Non considered a component of critical care services Cardioversion –Electrical shock delivered to the heart to convert an abnormal heart rhythm back to a normal rhythm 12/7/201539

40. Cardiovascular Therapeutic Services and Procedures Thrombolysis – Dissolving of a blockage by a thrombus clot in a vessel Coronary stent – wire metal mesh tube placed inside an artery to hold the vessel open Angioplasty – dilate and open a blocked artery 12/7/201540

41. Monitoring Heart Activity Cardiography (93040 – 93042) –Codes for professional component, technical component and global Implantable and Wearable Cardiac Device Evaluations (93279-93299) Cardiac Stress Tests –Activity or pharmaceutical 12/7/201541

42. Echocardiography (93303-93352) Diagnostic ultrasound of the heart M-mode recording – used to measure chamber dimensions and to establish the timing of events Doppler echocardiography – records the direction and velocity of blood flow Color-flow mapping – allows images of the blood to be displayed 12/7/201542

43. Cardiac Catheterizations (93451-93581) Most common access point – femoral artery Right or left heart catheterization? 12/7/201543

44. Cardiac Anomalies Septal Defect – holes in the walls of the pump separating the atria and ventricles Repair of Septal Defect –93580-93581 –Transcatheter Closure 12/7/201544

45. Intracardiac Electrophysiological Procedures/Studies 93600-93662 Percutaneous Indications - Cardiac arrythmias causing: Palpitations – irregular heart beats Syncope – loss of consciousness Cardiac arrest 12/7/201545

46. Peripheral Arterial Disease (PAD) Rehabilitation is reported per session Narrowing or blockage of the arteries in the legs Symptoms: –Cramping –Aching –Numbness 12/7/201546

47. Modifiers 26 – Professional Component TC – Technical Component LC – Left Circumflex, Coronary Artery LD – Left Anterior Descending Coronary Artery RC –Right Coronary Artery 80 – Assistant Surgeon 51 – Multiple Procedures 52 – Reduced Services 12/7/201547

48. The End 12/7/201548