1. UNDERSTANDING THE HEART OF LIFE
Diana R. Phelps CPC, CPC-I, CEMC Approved ICD-10-CM Instructor

2. It keeps ticking!

3. OBJECTIVES Define abbreviations and key terms
What makes the heart work
ICD-10-CM common codes
Cardiac procedures and surgeries
Anatomic concepts/dissection

4. HEART Heart shaped candy Valentine cards Broken heart songs
Cross your heart to make a promise
Emotions making heart beat faster (scared or excited)

5. COMMON ABBREVIATIONS A Fib Atrial Fibrillation AV Arteriovenous
CABG Coronary Artery Bypass Graft
CAD Coronary Artery Disease
CVP Central Venous pressure
CVAD Central Venous Access devices
EEG/EKG Electrocardiogram
EPS Electrophysiology study
LAD or LD Left Anterior Descending (coronary artery)
LC or LCX Left circumflex (coronary artery)
LM Left Main (coronary artery)

6. COMMON ABBREVIATIONS MI Myocardial Infarction
PTCA Percutaneous transluminal coronary angioplasty
PAD Peripheral artery disease
PICC Peripheral inserted central catheter
RCA or RC Right Coronary Artery
RI Ramus Intermedius (coronary artery)
TIPS Transvenous intrahepatic portosystemic shunt
SPECT Single-proton emission computed tomography
VSD Ventricular Septal Defect

7. WHAT IS THE HEART? Muscle Key organ of the circulatory system
Size of a man’s fist
Weighs approximately 9-15 ounces
Beats involuntarily
Beats an average of 70 minutes a minute, 100,000 times a day, 3.5 billion or more in a long life time, pumping about 2,000 gallons of blood
Consists of the heart and blood vessels: arteries; and veins
Cyanosis (bluish color)

8. WORKING THAT HEART MUSCLE
Located:
Left of the middle of your chest
Behind and slightly to the left of your breastbone (sternum)
Sends blood around your body
Blood provides your body with oxygen and nutrients
It carries away waste

9. WHAT’S INSIDE THE HEART?
Dual pump that never stops beating
Left side sends blood to the body
Right side sends blood to the lungs
Four chambers:
Top chambers- Right Atria and Left Atria
Holding stations for incoming blood
Bottom chambers-Right Ventricle and Left Ventricle
Pumps blood out of the heart

10. WHAT DO THE VALVES DO? Multiple valves Tricuspid Valve Pulmonary Valve
Keeps blood from flowing backwards into right atrium
Pulmonary Valve
Controls blood flow from the right ventricle into the pulmonary arteries
Carries blood to your lungs to pick up oxygen
Prevents backup into right ventricle
Mitral Valve (Bicuspid)
Lets oxygen-rich blood from your lungs pass from the left atrium into the left ventricle
Keeps blood from backing up toward lungs when left ventricle makes its powerful contraction
Aortic Valve
Opens the way for oxygen-rich blood to pass from the left ventricle into the aorta, our body’s largest artery
Prevents backup from aorta

11. WHAT IS THE HEART MADE OF?
Septum
Separates the left side and right side of the heart
Cardiac Muscle
Contracts rhythmically of its own accord
Myocardium
Contracting muscle
Striated muscle fibers interlaced into bundles
Epicardium
Pericardial sac
Tough membranous bag
Surrounds the heart
Smooth membrane
Attached by ligaments to your spinal column, diaphragm, and other parts of your chest
Endocardium
Lines the inner surface

12. THE CONDUCTION SYSTEM
Electrical impulses from your heart muscle (myocardium) cause your heart to contract
Begins in the sinoatrial (SA) node
Located top of the right atrium
Heart’s “natural pacemaker”
Travels through the muscle fibers of the atria and ventricles, causing contraction
Sends at a certain rate, but may change due to physical demands, stress, or hormonal factors

13. HEARTBEAT One complete contraction makes a heartbeat
Each involves a sequence of events
Different parts contracting at different times
Rhythmic “lub-dub” noise is the valves snapping shut.
First sound (lub) happens when the mitral and tricuspid valves close
Second sound (dub) happens when the aortic and pulmonary valves close after the blood is squeezed out of the heart
Pulse-heart rate
Resting should be between beats per minute
Modified cardiac muscle, the sinoatrial node, is the pacemaker
Sends out a wave of electricity to the walls contracting about 70 times a minute
Nerve signals from the brain can speed it up during exercise or stress

14. GOT THE BEAT ? One hard worker! Heart fills with blood
Muscle contracts to squirt the blood along
Heart contracts, it squeezes (try squeezing your fist)
Does it day and night, all the time
One hard worker!

15. BLOOD VESSELS Arteries Veins Capillaries
Carry blood away from the heart
Carry oxygenated blood
Thicker walls than veins, to withstand the force of the blood pumping directly out of the heart
Veins
Carry blood back to the heart
Carry deoxygenated blood
Capillaries
Connect arteries and veins
Only one cell thick, so that chemicals can pass between the blood and the body’s tissues

17. WHAT IS BLOOD?
Blood
A liquid tissue, consisting of trillions of cells suspended in a watery liquid called plasma
Makes up 55 percent of blood
Body’s transportation system (keeping all tissues and organs supplied with the chemicals needed for life and removing waste.
Red blood cells
Life-giving gas oxygen in the lungs and release it throughout the body
Single drop contains about five million tiny cells
Around 44 percent in the body
Packed with red protein hemoglobin, which binds the oxygen and then releases it where it is needed
White blood cells
Destroy germs and damaged tissues
Produce chemicals called antibodies, that stick to germs to make them easier to kill
Single drop contains about 7 thousand cells
Patrols the body like soldiers, swallowing germs

18. GREAT CIRCULATION
Movement of the blood through the heart around the body is called “circulation”
Takes less than 60 seconds to pump blood to every cell in your body
It needs this stead flow to keep it working
Delivers oxygen to all the body’s cell in your body
Without oxygen, cells die and eventually the person dies
Left side of the heart sends that oxygen-rich blood out to the body
Body takes oxygen out of the blood and uses it in your cells
When cells use the oxygen, they make carbon dioxide and other stuff that gets carried away
It’s like blood delivers lunch to the cells and then has to pick up the trash
Vessels of this network if laid end-to-end, could extend for about 60,000 miles (enough to circle the earth more than twice)

19. ICD-10-CM COMMON HEART CONDITIONS
Acute Rheumatic Fever (I00-I02)
Complication of strep throat with Group A streptococci that is left untreated
Appears 2-4 weeks after the strep infection
Weakens the heart, and can, in rare, circumstances, cause heart failure
EXAMPLE: I01.2 Acute rheumatic myocarditis
Chronic Rheumatic Fever or Disease (I05-I09)
Complications such as mitral valve disease, tricuspid valve, multiple valve and rheumatic heart diseases
EXAMPLE: I08.1 Rheumatic disorders of both mitral and tricuspid valves

20. ICD-10-CM COMMON HEART CONDITIONS
Note: Above majority of the codes they state “Use addition code to identify:
Exposure to environmental tobacco smoke (Z77.22)
History of tobacco dependence (Z87.891)
Occupational exposure to environmental tobacco smoke (Z57.31)
Tobacco dependence (F17.-)
Tobacco use (Z72.0)
Hypertension (HTN) (I10)
Blood pressure in the arteries is elevated
Controlled or uncontrolled
Benign, essential, malignant or unspecified

21. ICD-10-CM COMMON HEART CONDITIONS
Hypertension with Heart Disease (I11.-)
If a causal relationship with hypertension is stated or implied
Hypertensive, or “due to hypertension”
I11. 0 has a note to use an additional code to identify the type of heart failure (I50.-) if present
I11.9 is used for hypertension without heart failure
Example: I11.0 Hypertensive heart failure with left heart failure
I50.1 Left ventricular failure
Same heart condition with hypertension, BUT without the causal condition documented it must be coded separately (heart condition and hypertension are separated and unrelated) Sequence in order of importance for the patient admission or encounter, according to documentation
Example: I51.7 Cardiomegaly
I Hypertension

22. ICD-10-CM COMMON HEART CONDITIONS
Hypertensive Chronic Kidney Disease (I12.-)
There is a presumed cause-and-effect relationship between hypertension and chronic kidney disease (CKD)
I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
Use additional code to identify the stage of chronic kidney disease (N18.-)
Use additional code to identify dialysis status (Z99.2)
EXAMPLE: I12.0 Hypertension chronic kidney disease with stage 5 CKD
N18.6 Chronic kidney disease, stage 2 (mild)
Z99.2 Dependence on renal dialysis

23. ICD-10-CM COMMON HEART CONDITIONS
Hypertensive Heart and Chronic Kidney Disease (I13.-)
There is a assume relationship between hypertension and chronic kidney disease, whether or not the condition is so designated.
If heart failure is present, assign an additional code from category I50- to identify the type of heart failure
The appropriate code from category N18, Chronic kidney disease, should be used as a secondary code
If a patient has hypertension, heart disease and chronic kidney disease then a code from I13 should be used, not individual codes from I11 or I12.
Patients with both acute renal failure and chronic kidney disease an additional code for acute renal failure is required
EXAMPLE: I Hypertension heart and chronic kidney disease with heart failure and stage 3 chronic kidney disease
I Heart failure, unspecified
N18.3 Chronic kidney disease, stage 3

24. ICD-10-CM COMMON HEART CONDITIONS
Hypertension, Secondary
Secondary hypertension is due to an underlying condition (2 code required)
One to identify the underlying etiology
One from category I15 to identify the hypertension
Sequencing is determined by the reason for admission/encounter
Hypertensive Cerebrovascular Disease
First assign the appropriate code from categories I60-I69
Followed by the appropriate hypertension code

25. ICD-10-CM COMMON HEART CONDITIONS
Ischemic Heart Diseases (I20-I25)
Angina Pectoris (I20.-)
Use additional code to identify presence of hypertension (I10-I16)
Acute MI (I21.-)
Subcategories identify STEMI or NSTEMI and location
STEMI- coronary artery is completely blocked and virtually all the heart muscle
NSTEMI- the plaque or blockage only partially occludes the coronary artery and only a portion of the heart muscle
Old MI (I25.2)
After 4 weeks
Arteriosclerosis (CAD) (I25.-)
Hardening of the arteries

26. ICD-10-CM COMMON HEART CONDITIONS
Endocarditis (I33-I39)
Inflammation or infection of the inner lining of the heart (endocardium)
Heart Failure (CHF) (I50)
Occurs when the heart cannot pump enough blood to supply the body’s other organs
Pericarditis (I30-I32)
Inflammation of the sac surrounding the heart (pericardium), caused by infection
Peripheral Arterial Disease (PAD) (I73.9)
Affects the arteries outside the heart and brain.

27. SURGERIES Cardiac Valves (TAVR/TAVI)
Coronary Artery Bypass Graft (CABG)
Central Venous Access –Tunneled VS Non-tunnel, ETC.
Nonselective / Selective
Pacemaker or Implantable Defibrillator
Transplant
Ventricular Septal Defect (VSD)

28. CARDIC VALVES (33361-33478) Divided on valve and CP bypass:
Aortic
Mitral
Tricuspid
Pulmonary
Transcatheter aortic valve replacement valve (TAVR) Implant (TVAI)
Via artery: Percutaneous, open or transaortic
Codes are divided based on the approach
are add-on codes reported in addition to more primary procedures

29. CORONARY ARTERY BYPASS GRAFT (CABG) (33510-33572)
Two types:
Traditional open chest
Keyhole (minimally invasive)
To code correctly ask:
How many grafts were performed
How many were arterial
Which artery (ies)
How many were veins
Which vein(s)
How were they procured
Saphenous
Upper Extremity
Did the patient have a previous CABG procedure performed

30. CABG

31. CABG (cont.) 33510-33516 Venous only
Saphenous vein and left internal mammary is included. Procurement of the upper extremity vein (+35500) or the femoropopliteal vein (+35572) can be billed as an additional code.
Arterial with or without veins
Saphenous vein and left internal mammary is included. Procurement of the upper extremity vein (+35500), upper extremity artery (+35600) or the femoropopliteal vein (+35572) can be billed as an additional code.
Venous add on codes can only be used with artery codes
If any of the veins are harvested endoscopy use add on code
Reoperation, CABG or valve procedure, more than one month after original operation

32. CENTRAL VENOUS ACCESS (36555-36598)
Placed for frequent access to bloodstream
Tip of catheter must terminate in the:
Subclavian vein
Brachiocephalic vein
Iliac vein
Inferior or superior vena cava
Right atrium
Code by:
Procedure (insertion, repair, replacement, removal)
Tunneled or non-tunneled
With pump or port
Patient age

33. NONSELECTIVE / SELECTIVE (34001-37799)
Only for non coronary vessels
Divided on whether it is artery or vein used
Catheters are placed into vessels for monitoring, removal, or repair
Nonselective: Direct placement without further manipulation
Catheter placement example is 36000, Introduction of needle into vein
Selective: Place and then manipulate into further order(s)
Catheter manipulated into second order of venous system ( example)
Vascular families are like trees or roads (See appendix L)
Main branch-first order
Second order
Third order

34. PACEMAKER OR IMPLANTABLE DEFIBRILLATOR (33202-33273)
Devices that assist heart in electrical function
Placed
Atrium, single chamber (uses 1 lead)
Ventricle, single chamber
Both atrium and ventricle (2 leads)
Biventricular :both ventricles and right atrium (3 leads)
Approach
Epicardial: Open procedure to place on heart
Transvenous: Through vein to place in heart
Type of service
Initial placement or replacement of all or part
Number of leads placed

35. VENTRICULAR SEPTAL DEFECT REPAIRS (33641-33697)
Closure of ventricular septal defect, with or without patch;
33684 with pulmonary valvotomy or infundibular resection (acyanotic) –double chambered right ventricle
33688 with removal of pulmonary artery band, with or without gusset
Closure of multiple ventricular septal defects;
33676 with pulmonary valvotomy or infundibular resection (acyanotic)
33677 with removal of pulmonary artery band, with or without gusset
Repair of atrial septal defect and ventricular septal defect, with direct or patch closure (this is combined ASD and VSD)
Can’t use 63 modifier (Procedure Performed on Infants less than 4 kg)

36. HEART/LUNG TRANSPLANTATION (33930-33944)
Donor cardiectomy-pneumonectomy (including cold preservation
33933 or Backbench work
Heart-lung transplant with receipt
cardiectomy-pneumonectomy
Donor cardiectomy (including cold
preservation)

37. KEEP YOUR HEART HAPPY Majority are born with healthy hearts
Heart is a muscle, to keep it strong you need to exercise
Eat a variety of healthy foods and avoid foods in high fats
Eat at least five servings of fruits and vegetables each day
Avoid sugary soft drinks and fruit drinks
Avoid excessive alcohol products
Don’t smoke. It can damage the heart and blood vessels
IT STARTED PUMPING BLOOD BEFORE YOU WERE BORN AND WILL CONTINUE THROUGHOUT YOUR WHOLE LIFE SO TAKE CARE OF IT!

38. ANATOMIC CONCEPTS/DISSECTING
Let’s start in dissecting.