Cardiovascular Systems

Cardiovascular Systems

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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 affect this system Understand cardiovascular procedures and surgeries, and where in CPT® to locate the relevant codes Introduce ICD-10-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 Our objectives for this chapter are: To master anatomical concepts for the cardiovascular system: Define key terms, and recognize common eponyms and acronyms: Explain the most common pathologies that affect this system; Understand cardiovascular procedures and surgeries, and where in CPT® to locate the relevant codes: Introduce ICD-10-CM and HCPCS Level II codes and coding guidelines as they apply to this system: and Supply examples and review material to improve your application of the above concepts.

Circulatory Systems Systemic Circulatory System Blood Vessels Arteries
Veins Pulmonary System Coronary System Portal System Lymphatic System The cardiovascular system consists of the heart and blood vessels; arteries; and veins. Together with the pulmonary, coronary, portal and lymphatic systems, these networks form the circulatory system. Every cell of the body requires nourishment to perform its particular function. This metabolism of the cell requires oxygen and the removal of degradation products. The circulatory system is essential to this critical process; other vital roles of this system include temperature control and immune functions. The heart is a muscular pump beating an average of 70 times a minute. It has four chambers, consisting of the right atrium and ventricle and left atrium and ventricle. The normal adult heart is about the size of a clenched fist, weighing about 12 ounces; medical conditions and athletic training can result in enlargement of this hard-working organ.

The next paragraph may sound complicated and seem like it is ahead of other information; try to follow the sequence of events in the function of the heart. This information will serve as an overview of things to be discussed in more detail to follow. Here goes: Deoxygenated blood enters the right atrium from the body via large vessels, the superior and inferior vena cava. Simultaneously, oxygenated blood from the lungs enters the left atrium via the pulmonary veins. During diastole, blood flows from the atria to the ventricles through the right and left atrioventricular valves, openings from the right atrium to the right ventricle and from the left atrium to the left ventricle. Even though both atria do contract, blood will flow from the atria into the ventricles without contraction of the atria, because the ventricles are both empty. After the ventricles are filled with blood, they contract, which is systole; blood is forced into the pulmonary artery from the right ventricle and into the aorta from the left ventricle, because the tricuspid and bicuspid valves close off the atrioventricular openings. This prevents backflow of blood from the ventricles to the atria. The chordae tendinae (heart strings), which connect the valve leaflets to the papillary muscles, prevent eversion of the leaflets during systole. The contraction of the ventricular musculature empties the ventricles, opening the semilunar valves of the aorta and pulmonary artery, allowing blood to flow. Deoxygenated blood flows through the pulmonary arteries to the lungs to be oxygenated; oxygenated blood in the aorta is delivered to the body. The cycle is repeated as deoxygenated blood from the body again fills the right atrium, and oxygenated blood from the lungs fills the left atrium.

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 Most of us learned at an early age that arteries carry blood containing oxygen, referred to as oxygenated blood, and veins carry deoxygenated blood. Pictures usually illustrate arteries (with oxygen) in red and veins (no oxygen) in blue. Think of cyanosis, the bluish coloration of the skin, nail beds, lips or mucous membranes due to deficient oxygenation of the blood. These body parts take on this bluish hue rather than “rosy-red” cheeks. A useful trivia question to know the answer to is: What artery carries deoxygenated blood? Answer – pulmonary artery. The pulmonary artery carries deoxygenated blood from the heart to the lungs for oxygenation. Arteries carry blood away from the heart to the body. The aorta is a large artery; next are smaller arteries connecting to arterioles and then capillaries. Capillaries are small tubes connecting arterial and venous sides of the circulation. These networks of small vessels are known as capillary beds. Oxygen, nutritional products, and other cellular materials pass from these very small capillaries to the cells. Veins are the vessels carrying less oxygenated blood to the heart from the capillary beds. Veins are similar to arteries, only thinner. Another difference between arteries and veins is that veins have valves. Valves help in the return of blood against gravity to the heart by preventing backflow of the blood. The by-products of cell metabolism pass from the cells to the lymph and then into the capillaries. As the vessels get bigger, they become venules and then veins; the large veins have already been mentioned – the superior (SVC) and inferior (IVC) vena cava, which empty into the right atrium.

Anatomy Anatomy of blood vessels
Arteries and veins have walls composed of three layers: Tunica intima – inner single layer of epithelial cells Tunica media – smooth muscle layer Tunica adventitia – white fibrous connective tissue Veins have less elastic and smooth muscle tissue and more fibrous connective tissue Veins capable of distention to adapt to changes in blood pressure and blood volume Arteries and veins have walls composed of three layers; the tunica intima, which is an inner single layer of epithelial cells, the tunica media which is a smooth muscle layer, and tunica adventitia, which is a layer of white fibrous connective tissue. Veins have less elastic and smooth muscle tissue and more fibrous connective tissue. Veins are capable of distention to adapt to changes in blood pressure and blood volume.

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 Right lymphatic duct drains into right subclavian vein Thoracic duct drains into left subclavian vein Both subclavian veins empty into the inferior vena cava The lymphatic system allows for the removal of extra tissue fluid, cellular debris, and infection from the body. The fluid collected is lymph; lymph nodes are located along lymphatic collecting networks or plexuses. Lymphatic vessels occur primarily where blood capillaries are found. Lymph nodes are small collections of lymphatic tissue through which lymph fluid is filtered on its way to the venous vessels. Lymph vessels drain into larger lymphatic vessels, which unite to drain into either the right lymphatic duct or the thoracic duct. The right lymphatic duct then empties into the right subclavian vein and the thoracic duct empties into the left subclavian vein. Lymph nodes stop bacteria, cancer cells, and other foreign material. This is why when cancer is found, lymph nodes are biopsied, removed, or visualized to see if the cancer has spread. Lymphocytes are cells of the immune system; they are produced in the spleen, thymus, bone marrow, and walls of the digestive tract. Lymphoma is a cancer of these cells.

Electrical Conduction in the Heart
Conduction begins in sinoatrial (SA) node of right atrium Nature’s pacemaker Firing causes contraction of muscle Moves to atrioventricular (AV) node Then to bundle of His along septum Right and left bundle branches go to each ventricle Then to Purkinje fibers along the surface of ventricles There is an electrical conduction system in the heart. The conduction begins in the sinoatrial node of the right atrium. It is identified in the CPT® Professional edition illustration of the right atrium. Electrical impulses go from the sinoatrial, or SA node to the atrioventricular, or AV node and then down along the septum and across the bottom of the heart. Here we find Purkinje fibers, which are very tiny signaling devices within the electrical system along the ventricle at the apex. Electrical signals cause the right and left atria to contract at the same time. This is followed by contraction of the ventricles. These electrical impulses are the basis of EKGs (electrocardiograms). Heart sounds are caused by the closing of the atrioventricular valves as the ventricles contract. These valves lie between the atria and ventricles; they prevent blood from flowing backward into the atria.

Circulatory Systems 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 Coronary Circulation Movement of blood through the tissue of the heart The heart can be viewed as three separate circulations concerning the heart – the pulmonary, the systemic, and coronary circulations. The pulmonary circulation on the right side of the heart pushes deoxygenated blood into the lungs. Here, carbon dioxide is removed, oxygen is added, and this blood flows to the left atrium. In the systemic circulation, oxygenated blood flows from the left atrium into the left ventricle to be pumped to the body to deliver oxygen and remove carbon dioxide. It then returns to the right atrium to complete the circuit. The coronary circulation refers to the movement of blood through the tissue of the heart.

Circulations Portal System
Directs blood from the intestines to the liver Liver processes the blood before the blood continues on to the heart Another circulatory system is the portal system, which is a subdivision of the systemic circulation. The portal system directs blood from the intestines to the liver where it is processed and then returned to the systemic circulatory system. There are over five hundred liver functions. The liver stores excess sugars, neutralizes harmful toxins and wastes, and produces amino acids, protein and fat.

Circulatory Systems Coronary Circulation Right coronary artery (RC)
Marginal branches Posterior interventricular branch (posterior descending) Left coronary artery Left circumflex artery (LC) Obtuse branches Left anterior descending artery (LD) Diagonal branches As mentioned, the coronary circulation refers to movement of blood through the tissue of the heart. The right and left coronary arteries come off the aorta, just above the aortic valve. The left coronary artery bifurcates almost immediately into the left circumflex and the left anterior descending coronary arteries. Later you will learn to use HCPCS modifiers when coding for percutaneous transluminal coronary artery procedures. The three coronary arteries and their branches are listed for you.

Great Vessels Great vessels Aorta Brachiocephalic trunk (innominate)
Left common carotid Left subclavian artery Pulmonary trunk which bifurcates to right and left pulmonary arteries Pulmonary veins (four) Superior vena cava Inferior vena cava Discussion of the circulatory system would not be complete without mentioning the great vessels. The great vessels are the aorta, the pulmonary trunk, which becomes the right and left pulmonary arteries, the pulmonary veins, and the superior and inferior vena cavae. Off the arch of the aorta are the branchiocephalic also known as the innominate artery, the left common carotid artery, and the left subclavian artery.

Heart Four (4) Chambers Two atria Two ventricles Three (3) layers
Endocardium Myocardium Epicardium Pericardial sac (double-walled membrane) Visceral pericardium Parietal pericardium The four chambers of the heart serve as brief storage depots for blood. The internal layer of the heart is a smooth lining of endocardium. This thin layer is very slippery and smooth. It allows blood to flow through the heart without sticking or stopping. Blood that “sits” tends to clot. The working muscle of the heart is the myocardium (myo- means muscle, -cardia means heart). When you look at a “cross-section” of the heart, it is obvious the left side is thicker and more muscular than the right. The left ventricle must push blood from the heart to the top of our heads, our fingertips and the end of our toes. You may have heard of a serious condition in some newborns – hypoplastic left heart – this is why the condition is so serious; babies with this problem don’t have any (or enough) muscle in the left ventricle to push blood to their bodies. Cardiac muscle is not under voluntary control; the heart rate is controlled electrically by special cardiac muscle fibers in the pacemaker portion of the heart, which is controlled by the autonomic (involuntary) nervous system. The external layer of the heart is the epicardium; it is also smooth. The exterior surface of the heart contains the coronary arteries. Critically important, these arteries feed and nourish heart muscle. Coronary or cardiac arteries provide the heart muscle with necessary nutrients and oxygen. The next layer is the pericardium, a double-walled membrane enclosing the heart and the roots of the great vessels. The visceral pericardium adheres to the surface of the heart, and the parietal epicardium is a tough membrane which covers the heart. The space between the layers contains a small amount of fluid, serving primarily as a lubricant between these layers.

Heart Pericardium Visceral layer adheres to the heart and the first few centimeters of the outside of the great vessels Parietal layer – outer layer Pericardial fluid Located in space between the visceral pericardium and the parietal layer 10 – 30 ml fluid to lubricate the heart’s surface Fluid can increase up to 300 ml without impeding the heart The pericardial cavity is a potential space between the layers of the pericardium. The pericardium protects the heart from rubbing against other organs. Medical records sometimes contain the notation: “no rubs,” which is a normal finding; meaning the pericardium is serving its purpose.

Heart Cardiac Tamponade
Compression of the heart caused by build up of pericardial fluid or blood Can lead to cardiac arrest Pericardiocentesis Procedure to drain fluid from pericardial sac At times the pericardium can become over-filled with fluid, which is a pericardial effusion, or inflamed, which is pericarditis, causing pressure or friction potentially affecting the function of the heart. Cardiac Tamponade, which can lead to cardiac arrest, is caused by compression of the heart from pericardial fluid or blood. Pericardiocentesis is a procedure used to drain the pericardial sac.

Heart Valves Atrioventricular valves
Tricuspid (3 leaflets) – right side of heart Bicuspid or Mitral (2 leaflets) – left side of heart Chordae tendineae (heart strings) attached to valve leaflets and the papillary muscles of the ventricle Keep valves from everting and provide support during systole Semilunar valves Pulmonary (Pulmonic) Aortic Heart valves serve critical functions and can create serious problems when damaged or not functioning well. Heart sounds, as already mentioned, are due to fluid vibrations resulting from closure of the valves. Closure of the tricuspid and bicuspid valves is responsible for the first heart sound; the closing of the pulmonary and aortic valves is responsible for the second heart sound. The pulmonary valve is at the entrance to the pulmonary vessels from the right ventricle; the aortic valve is between the left ventricle and the ascending aorta. Both of these semilunar valves have three cusps that prevent backflow of blood. This brief description of the anatomy of the heart and circulatory system attempts to explain a very complex process. We don’t have to think about it for it to happen – our heart beats day and night, sunshine or rain. As you will see, things can go wrong in many ways. Blood vessels need to be patent, valves must function properly, the heart muscle must be strong and working well, coronary vessels must feed this muscle, and electrical impulses must work. A heart attack, or myocardial infarction, occurs when cardiac muscle is injured or dies. At any time, this ever reliable pump can falter or fail. Disease, injury, or birth defects can impact all of the integral components of this system and jeopardize other vital functions of the body.

ICD-10-CM Coding Chapter 09: Diseases of the Circulatory System
Rheumatic Heart Disease Hypertensive Disease Ischemic Heart Disease Pulmonary Heart Disease and Diseases of Pulmonary Circulation Other Forms of Heart Disease Cerebrovascular Disease Diseases of Veins, Lymphatic Vessels and Lymph Nodes Other Disorders of Circulatory System Most diagnostic codes for the cardiovascular system are found in ICD-10-CM chapter 9, Diseases of the Circulatory System (I00-I99). Common cardiovascular conditions fall into these categories: Rheumatic Heart Disease Hypertensive Disease Ischemic Heart Disease Pulmonary Heart Disease and Diseases of Pulmonary Circulation Other Forms of Heart Disease Cerebrovascular Disease Diseases of Veins, Lymphatic Vessels and Lymph Nodes Other Disorders of Circulatory System

Diseases of the Circulatory System
Acute rheumatic fever (I00-I02) 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 Persistent inflammation of heart lining due to rheumatic heart disease. Rheumatic fever (I00-I02) is a complication of strep throat with Group A streptococci that is left untreated. This is a rare, but serious life-threatening condition. The main symptoms are fever, muscle aches, swollen and painful joints. Some patients have a red rash that accompanies the acute symptoms. These symptoms typically appear 2-4 weeks after the strep infection. This can cause rheumatic heart disease that weakens the heart and can, in rare, circumstances, cause heart failure. Chronic rheumatic fever is also called chronic rheumatic heart disease (I05-I09)and includes complications such as rheumatic mitral valve diseases (I05), rheumatic aortic valve disorders (I06), rheumatic tricuspid valve disorders (I07) multiple valve diseases (I08) and other rheumatic heart diseases (I09).

Cardiac Cycle Blood pressure
Measurement of the pressure of blood exerted within the blood vessels - Sphygmomanometer 120/80 mm Hg 120 = Systole 80 = Diastole Hypertensive Disease is next. Commonly used phrases include hypertension, high blood pressure or HBP, or HTN. Blood pressure is measured with a sphygmomanometer, a cuff placed around the arm and inflated with air until it compresses the artery and blocks blood circulation locally. Using a stethoscope to listen over the area, pressure is gradually released in the cuff.

Cardiac Cycle Two Phases Systole
Blood is ejected from the ventricles into the body’s circulatory path (highest pressure against the walls of the blood vessels) Diastole Ventricles relax and fill with blood from the atria (lowest pressure against the walls of the blood vessels) The first sound heard is the systolic blood pressure or systole, which is the top number; as the pressure is gradually released, the point where the sound completely disappears is the diastolic blood pressure, or diastole, which is the bottom number; in other words, systolic over diastolic. If systolic is 120, and diastolic is 80, blood pressure is reported as 120 over 80. It is difficult to list “normal” values for blood pressure measurements. There are absolute “highs” and “lows.” More often, a change in blood pressure from a previous measurement is meaningful. For this reason, it helps to know what is normal or recent for a person’s blood pressure to know if a change is significant or worrisome.

ICD-10-CM: Hypertension
Hypertensive Disease I10 Hypertension Guidelines I.C.9. Many guidelines found in the Tabular List for these categories Hypertension (HTN), or high blood pressure, is a chronic medical condition in which the blood pressure in the arteries is elevated. It is classified as either primary (essential) or secondary. About 90–95 percent of cases are termed primary hypertension, which refers to high blood pressure for which no medical cause can be found. The remaining 5–10 percent of cases (secondary hypertension) is caused by other conditions affecting the kidneys, arteries, heart, or endocrine system. Combination codes are used to report Hypertension with other diseases. Hypertension is assigned with code I10 and is used whether the hypertension is controlled or uncontrolled and whether benign, essential, malignant, or unspecified. The combination codes are used when hypertension is accompanied by other conditions, such as heart disease and chronic kidney disease. Look in the Index to Diseases and Injuries for Hypertension, hypertensive I10. I10 Essential (primary) hypertension In the Tabular list, I10 includes Hypertension that is arterial, benign, essential, malignant, primary, or systemic. The ICD-10-CM Official Guidelines for Coding and Reporting, Section I.C.9.a., gives extensive direction on code assignment when accompanied by heart disease and chronic kidney disease. In the Tabular List, above code I10 an instructional note states to use an additional code to identify tobacco use, exposure to smoke or tobacco, or nicotine dependence, if applicable.

ICD-10-CM: Myocardial Infarction
MI Acute MI Old MI STEMI (ST elevation) NSTEMI (non-ST elevation) An MI, or heart attack, is a sudden decrease in coronary artery blood flow resulting in death of the heart muscle. When an MI is suspected, the provider often orders lab tests to determine the levels of creatinine phosphokinase (CPK) and troponin in the patient’s blood. Elevated levels of CPK and troponin can indicate damage to the heart muscle. If you have a diagnosis of elevated CPK or elevated troponin, the elevated lab result is coded from Abnormal findings (R70-R79) in ICD-10-CM. Once a myocardial infarction (MI) has been diagnosed, it is classified based on the affected heart tissue and the time frame in which it occurs. For an acute MI, select from category I21 according to site. Subcategories I20.0-I21.2 and I21.3 identify a ST elevation myocardial infarction (STEMI) in a STEMI, the coronary artery is completely blocked and virtually all the heart muscle being supplied by the affected artery starts to die. Code I21.4 is used for NSTEMI (non-ST elevation myocardial infarction), nontransmural MIs, or acute subendocardial MIs. In an NSTEMI, the plaque or blockage only partially occludes the coronary artery and only a portion of the heart muscle being supplied by the affected artery dies. There is an instructional note under categories I21 and I22 in the Tabular List to Use additional code, if documented, to identify use or exposure or dependence to tobacco, or status post administration of tPA (rtPA). There is only one code for an old MI, I With an old MI, the patient is asymptomatic and does not require any further treatment. If a patient presents with symptoms less than four weeks post-MI, it is considered acute. If the patient requires continued care or is symptomatic after 4 weeks, the appropriate aftercare code is used and not a code from category I21.

ICD-10-CM: Arteriosclerosis
If documentation specifies CAD of a native coronary artery, and the patient is not a heart transplant patient, select a code from subcategory I Atherosclerotic heart disease of native coronary artery with angina pectoris. The 6th character of the code will identify the presence of angina or spasm. Whether the patient has had a previous CABG is important for several reasons: ICD-10-CM coding may be different if the patient has atherosclerosis of native coronary arteries (I25.1-) versus previous bypass grafts (I25.7-). The patient has CAD and documentation specifies no history of a prior coronary artery bypass graft (CABG). The patient had a prior percutaneous transluminal coronary angioplasty (PTCA) of a native artery and the patient is admitted with reocclusion of this lesion. Arteriosclerosis is hardening of the arteries. If it is arteriosclerosis of the coronary arteries, assign a code from category I25 Chronic ischemic heart disease. Code selection indicates whether the atherosclerosis is of native artery, bypassed artery, or transplanted heart. Angina pectoris is characterized by chest pain and is common in patients with arteriosclerosis. When both conditions are documented, a causal relationship is assumed between arteriosclerosis and angina pectoris unless it is specifically stated the angina is due to another cause. Combination codes are used to report arteriosclerosis with angina pectoris (I25.11-, I25.7-). Since the angina is included in the code it is not necessary to report it separately. Overuse of I25.10 Atherosclerotic heart disease of native coronary without angina pectoris is a common error. Apply I when documentation shows that the patient has had a coronary artery bypass graft (CABG) and the physician did not specify where the coronary artery disease (CAD) is being treated and whether it is in a native vessel or in one of the replaced vessels. If documentation specifies CAD of a native coronary artery, and the patient is not a heart transplant patient, select a code from subcategory I Atherosclerotic heart disease of native coronary artery with angina pectoris. The 6th character of the code will identify the presence of angina or spasm. Whether the patient has had a previous CABG is important for several reasons: ICD-10-CM coding may be different if the patient has atherosclerosis of native coronary arteries (I25.1-) versus previous bypass grafts (I25.7-). The patient has CAD and documentation specifies no history of a prior coronary artery bypass graft (CABG). The patient had a prior percutaneous transluminal coronary angioplasty (PTCA) of a native artery and the patient is admitted with reocclusion of this lesion.

ICD-10-CM: Endocarditis
Inflammation or infections of the inner lining of the heart. Code range I33-I39 Endocarditis is inflammation or infection of the inner lining of the heart (endocardium). Left untreated, it can damage or destroy heart valves. Bacterial infection is the most common source of endocarditis, but it may be caused by fungi. In some cases, no cause can be identified. Most codes for endocarditis can be found in code range I33-I39. Rheumatic endocarditis is an exception: Acute rheumatic endocarditis is coded as I01.1 and chronic rheumatic endocarditis as I09.1. Sometimes multiple codes are necessary to report acute endocarditis when the infectious organism is known or when the underlying disease is known. The order will depend on the type of endocarditis. For example, acute streptococcal endocarditis is codes I33.0, B95.-.

ICD-10-CM: Heart Failure
Category I50 Heart failure has a code first note in ICD-10-CM. The note indicates to code first heart failure following surgery (I97.13-) and then a code from category I50 as the additional code. To code heart failure following cardiac surgery in ICD-10-CM, two codes are reported: I Postprocedural heart failure following cardiac surgery I50.9 Heart failure, unspecified Note: Heart failure can be further specified as acute, chronic, acute on chronic, systolic, diastolic, or combined when documented. Heart failure (also, congestive heart failure or CHF) occurs when the heart cannot pump enough blood to supply the body’s other organs. Multiple codes may be necessary to describe the condition. At other times, combination codes may be used. For example, hypertensive heart failure (explained above) requires at least two codes. In contrast, acute combned systolic and diastolic heart failure are reported with code I50.41.

ICD-10-CM Pericarditis Peripheral Arterial Disease Valve Disorders
Pericarditis is inflammation of the sac surrounding the heart (pericardium), caused by infection. Chest pain is significant on inspiration, and onset often is sudden and can be worse when lying down. Most codes for pericarditis are found in code range I30-I32. Multiple codes may be necessary to describe the patient’s condition if underlying disease is documented. PAD is similar to coronary artery disease, except it affects the arteries outside the heart and brain. It is the most common type of peripheral vascular disease (PVD). If the only diagnosis given is PAD or PVD, report unspecified code I73.9. If the PVD is due to diabetes, a combination code must be used to show the condition: E08-E13 with fifth and sixth character of .51 or .52 depending on the presence of gangrene. There are various heart valve disorders. Most prominent are stenosis, regurgitation, and prolapse. Valve stenosis is a condition of the heart in which one or more of the heart valve openings is narrow (or stenotic) and restricts the flow of blood through the heart. Valve regurgitation occurs when the valve does not close properly and blood backflows, or leaks back, into the heart chamber. Valve prolapse occurs when valve leaflets prolapse, or fall backward, into the heart chamber. ICD-10-CM code selection is driven by which valve(s) are affected and whether the condition is congenital or acquired. For congenital heart valve stenosis, see categories Q22 and Q23. For non-congenital disorders, you must know if the condition is rheumatic, acute, or involves multiple valves.

Terms Apex—bottom point of the heart Retrograde—against the current
Antegrade—with the current (blood flow) Cardioversion—shock treatment to the heart CPR—Cardiopulmonary resuscitation Tachycardia—rapid beating of the heart Pacing—refers to electrical activity of the heart Here are a few terms worth knowing. Apex of the heart is the bottom point where the ventricles come together. Retrograde is against the current (blood flow). Antegrade is with the current. Cardioversion is shock treatment to the heart to reestablish a normal pacing rhythm of the heart and can be performed either internally or externally. CPR stands for cardiopulmonary resuscitation, when pressure is applied on the chest to cause air movement into the lungs and to try and establish a heartbeat. Tachycardia is rapid beating of the heart, usually used to indicate a rate over 100 beats per minute (BPM). Pacing refers to the electrical activity of the heart. The sinoatrial node (SA node) location was previously mentioned; next is the atrioventricular node (AV node), and then the bundle of His (pronounced “hiss”), which is in the upper ventricles, and is the pacing location. So the electrical activity travels from the SA to the AV node, to the bundle of His, and then to the Purkinje fibers of the cardiac muscle.

CPT Coding Surgical Section - Cardiovascular System — 33010-37799
Heart and Pericardium – Radiology Section Heart – Vascular Procedures – Diagnostic Ultrasound (various CPTs) Radiologic Guidance – Nuclear Medicine Diagnostic, Cardiovascular System – Medicine Section Cardiovascular – Noninvasive Vascular Diagnostic Studies – The cardiovascular system procedures are reported using codes from a couple of areas of CPT®. In the Surgery section, Cardiovascular System is There are very good detailed and labeled illustrations of the heart, arteries and veins at the beginning of this section. Following this section is the Radiology section where you will find codes for radiologic diagnostic studies of the Heart, Vascular Procedures, Radiologic Guidance, and Nuclear Medicine Diagnostic studies for the cardiovascular system. We next jump to a section of the Medicine Chapter, also Cardiovascular and Noninvasive Vascular Diagnostic Studies.

Pericardium Pericardiocentesis (33010-33011) Diagnostic test
Cardiac tamponade Radiological supervision and interpretation (76930) Pericardotomy for removal of clot/FB (33020) Add a note by this code to use if performed by thoracoscopy Pericardial window (33025) (For thoracoscopy [VATS] pericardial window, use 32659) Note: an illustration of a cross section of the heart is found on page 192 in the 2017 CPT Professional codebook. In the Cardiovascular System section, look at the picture of a cross-section of a heart at the beginning of this section for a good review of the anatomy of the heart. Beginning with the pericardium, Pericardiocentesis; initial, is defined as a needle drainage of the pericardium. Remember from the anatomy discussion at the beginning, the pericardium, or pericardial sac, is a potential space between the smooth sacs surrounding the heart. Potential space means nothing other than a small amount of fluid for lubrication should be in this space. When there is fluid filling this cavity, it can impede the function of the heart and can be a sign of infection. Pericardiocentesis may be necessary to remove the fluid to relieve symptoms or to make a diagnosis.

Pacemakers/Defibrillators (33202- 33273)
Pacemaker System Generator Electrodes (leads) Note Temporary or permanent? Single or dual chamber? What is being addressed – electrodes, pulse generator, or both? NOTE: Temporary pacemakers are noted as “separate procedures” Codes following in this section cover a variety of topics, including cardiac tumors, pacemakers, or implantable defibrillator. As described earlier, cardiac muscle contractions are not under voluntary control. Heart rate is regulated by a pacemaker comprised of special cardiac muscle fibers under control of the autonomic (involuntary) nervous system. In the case of an “artificial” pacemaker, it refers to an artificial or man-made system to regulate the rate of activity.

Pacemaker or Implantable Defibrillator
Permanent Pacemaker system includes: a pulse generator (containing electronics and a battery), and one or more electrodes (leads) Generator is placed in a subcutaneous pocket created either in a subclavicular site, or underneath the abdominal muscles, just below the rib cage Electrodes are inserted through a vein (transvenous), or they may be placed on the surface of the heart (epicardial) by thoracoscopy or thoracotomy. A pacemaker system related to the heart consists of a pulse generator, including battery, and one or more electrodes or leads.

Guidelines Replacement of a pacemaker pulse generator: Single codes exist for removal and replacement of a single lead system (33227), a dual lead system (33228) or multiple lead system (33229) Replacement of an implantable defibrillator pulse generator Single lead system (33262), dual lead system (33263) or multiple lead system (33264) For Radiological supervision and interpretation see When a pulse generator is replaced for a pacemaker or an implantable defibrillator generator, there is one code to describe the procedure based on the number of leads. An implantable defibrillator system includes a pulse generator and one or more electrodes (leads). These devices work with a combination of anti-tachycardia pacing, low-energy cardioversion, or defibrillating shocks in treating ventricular tachycardia or ventricular fibrillation. A more detailed description of placement of these devices is given in CPT®. When a temporary pacemaker is employed, the power source, the generator, is outside the body, and the electrodes travel through veins to the specific area of the heart.

Guidelines Insertion of new or replacement of permanent pacemaker with transvenous electrodes(s) ( ) Insertion of implantable defibrillator pulse generator with single, dual, or multiple leads ( ) Note: , , 33239, and are re-sequenced codes and are out of numerical sequence. Implanted pacemakers with single, dual, or multiple leads are listed in Implanted cardioverter-defibrillators with single, dual or multiple leads are listed in An additional electrode may be required for pacing the left ventricle. The electrode is placed in the cardiac vein over the left ventricle.

Biventricular Pacing An additional electrode may be required for pacing of left ventricle. The electrode is placed in the cardiac vein over the left ventricle. Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and /or replacement of existing generator)  Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (When epicardial electrode placement is performed, report in conjunction with 33202, 33203) Biventricular (2 ventricles) pacemaker codes are When an epicardial lead placement is performed, report in conjunction with or The “electrodes” or “leads” discussed in these sections of CPT® refer to the wires running to the specific area of the heart muscle to be stimulated. There are also specific codes for repositioning and removal of these leads.

Patient underwent removal of a complete dual pacemaker system. A dual implantable defibrillator system was placed with two transvenous electrodes, along with a biventricular electrode with use of fluoroscopy. Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s) single or dual chamber Removal of transvenous pacemaker electrodes; dual lead system electrode Insertion of biventricular pacing electrode (this is an add-on code – modifier 51 is not applicable) Removal dual system pacemaker generator Carefully read the codes in this section and the guidelines. Four codes are needed when a pacemaker system is removed and replaced by a dual implantable defibrillator system, along with a biventricular electrode, and yet there are single codes available for other services, such as the removal and replacement of a pulse generator.

Electrophysiologic Operative Procedures
Incision ( ) Operative tissue ablation codes are only to be reported when there is no concurrently performed procedure that requires median sternotomy or cardiopulmonary bypass Use add-on codes for operative tissue ablation performed at the time of other cardiac procedures. Endoscopy (33265 – 33266) Electrophysiologic Operative Procedures describe the surgical treatment of dysrhythmia or defective rhythm. This surgery can involve ablation, which is defined as removal or destruction of the function, by way of different methods including surgical incision or use of energy sources, such as laser and microwave. There are add-on codes for tissue ablation procedures performed at the time as other cardiac procedures. Remember, arrhythmia means a loss of rhythm, or an irregularity of the heartbeat. Arrhythmia and dysrhythmia are often used interchangeably.

Heart (Including Valves) and Great Vessels
– repair of cardiac wound and repair of great vessels Great vessels: Superior vena cava Inferior vena cava Pulmonary artery Four pulmonary veins Aorta Heart (Including Valves) and Great Vessels lists repair of cardiac wound, and repair of these vessels with and without bypass. The “great vessels” are the large vessels in the mediastinum (median or middle area of the thoracic cavity or chest) attached to the heart and include the superior and inferior vena cava, pulmonary artery, four pulmonary veins, and the aorta. They carry blood to and from the heart.

Cardiac Valves ( ) Transcatheter aortic valve replacement (TAVR)/ Transcatheter aortic valve implantation (TAVI) ( ) Separate codes for transcatheter approaches Add-on codes for cardiopulmonary bypass Codes include angiography, radiologic supervision and interpretation used for guidance, access, valvuloplasty, positioning, deploying valve, temporary pacing (33210) and closure of arteriotomy These procedures require 2 surgeons – report modifier 62 Diagnostic coronary angiograms and cardiac catheterization at the same time may be reported separately if not intrinsic to TAVR/TAVI and guidelines are met. Use for transapical approach (eg, left thoracotomy) Cardiac Valves lists transcatheter aortic valve replacement and implantation codes based on percutaneous access approach. Add-on codes are available for cardiopulmonary bypass based on type of cannulation. These codes include angiography, radiologic supervision and interpretation performed to guide TAVR/TAVI, percutaneous access, placing the access sheath, balloon aortic valvuloplasty, advancing the valve delivery system, temporary pacemaker insertion and closure of the arteriotomy. These procedures require two physician operators and all components of the procedures are reported using modifier 62. Diagnostic coronary angiograms and diagnostic cardiac catheterizations may be reported separately if not intrinsic to TAVR/TAVI and guidelines are met.

Cardiac Valve Procedures
Aortic Valve ( ) Mitral Valve ( ) Tricuspid Valve ( ) Pulmonary Valve ( ) Codes for open procedures involving the cardiac valves are listed individually for the aortic, mitral, tricuspid, and pulmonary valves. This includes “-plasty”, which is surgical shaping or molding, and “-otomy”, which is cutting or opening, repair, and replacement of the valve.

CABG Coronary Artery Bypass Graft Venous (33510-33516)
Arterial-Venous ( ) Arterial ( ) Reoperation (+33530) The anatomy discussion at the beginning of this presentation stressed the critical nature of the coronary arteries in the function of the heart. Coronary arteries arise from the aorta and are small vessels feeding oxygen and nutrients to the myocardium. Each coronary artery has a specific name; one of the most important is the left anterior descending (LAD) artery that supplies a large portion of the left ventricle – very important! When blocked, treatment includes bypassing these vessels with grafted vessels, called a CABG for Coronary Artery Bypass Graft, arterial and venous, to restore blood flow.

CABG Coronary Artery Bypass using Venous Grafting only (33510-33516)
Used to report coronary artery bypass procedures using venous grafts only Not used for combined arteriovenous grafts Procurement of the saphenous vein is included in the relative value units for these codes and not separately reportable unless performed endoscopically (+33508) Report procurement of other veins separately Upper extremity vein (35500) Femoropopliteal vein (35572) To perform these procedures, vessels from other parts of the body are harvested – such as the saphenous vein in the leg; this procedure is included in the work for codes and is not reported as a separate service or as a co-surgery. Check CPT® for specific codes to report other possible veins used, such as from an upper extremity or the femoropopliteal vein. When a surgical assistant performs the procurement, report modifier 80.

CABG Arterial Grafting for Coronary Artery Bypass (33533-33536)
Arterial includes the use of the following arteries: The internal mammary artery The gastroepiploic artery The epigastric artery The radial artery and/or Arteries procured from other sites Artery graft from upper extremity is reported separately (35600) Arterial grafting for coronary artery bypass includes the use of arteries such as the internal mammary, gastroepiploic, epigastric and radial artery. Add-on code is used for an arterial graft from the upper extremity.

CABG Combined Arterial-Venous Grafting for Coronary Artery Bypass ( ) ( ) To report combined arterial-venous grafts, you must report two codes: The arterial-venous graft code ( ) The arterial graft code ( ) Add-on code Coronary endarterectomy, open Venous and arterial grafts used during the same procedure are add-on codes, Arterial grafts for coronary artery bypass specify the number of grafts from a single graft to four or more grafts. There is also an add-on code for coronary endarterectomy; meaning the excision or removal of a blockage of the coronary artery, such as an atheromatous deposit.

CABG Coronary artery bypass with left internal mammary artery to the left anterior descending, and arterial graft from the left radial artery to the first diagonal of the LAD. Saphenous vein graft to the ramus intermedius. Harvesting of the saphenous vein was endoscopic. coronary arterial grafts venous graft 35600 Harvest of upper extremity artery 33508 Harvest by endoscopy An example is given in this slide to show you how to code a coronary artery bypass procedure using arterial and venous grafts, with one arterial graft from the upper extremity. Endoscopy was used for vein procurement.

Cardiac Anomalies ( ) Single Ventricle and Other Complex Cardiac Anomalies ( ) Septal Defect ( ) Sinus of Valsalva ( ) Venous Anomalies ( ) Shunting Procedures ( ) Transposition of the Great Vessels ( ) Truncus Arteriosus ( ) Aortic Anomalies ( ) Cardiac anomalies, which are a deviation from the average or normal, involve the walls (septum) of the chambers, great vessels, and muscle (myocardium) of the heart. A septal defect indicates blood flow through the septum. An example of this is an atrial septal defect, where blood is flowing from the right atrium to the left atrium. Prior to birth in the fetal heart, blood flows through the foramen ovale, a normal opening in the septum between the right and left atria. Before birth, this allows blood to bypass the lungs, because the fetal lungs aren’t providing oxygen – that comes from mom. The ductus arteriosus is another fetal modification of blood flow: It connects the pulmonary artery to the aorta, again bypassing the lungs with oxygenated blood from mom. At birth, pressure changes in baby’s circulation coincident with baby’s miraculous first breath close these openings, because baby needs to oxygenate its own blood. Cardiac anomalies can occur when these connections or shunts don’t close completely – thus a “patent foramen ovale” (a septal defect) or a “patent ductus arteriosus” result. Tetralogy of Fallot is a set of congenital cardiac defects, including a ventricular septal defect (VSD), pulmonic valve stenosis, dextroposition of the aorta, and hypertrophy of the right ventricle.

Heart/Lung Transplantation
Distinct Components of Physician Work Cadaver donor cardiectomy with or without pneumonectomy Backbench work Recipient heart with or without lung allotransplantation Heart /Lung Transplantation can include a cadaver heart to include the harvesting and cold preservation of the donor heart with or without lung transplantation. Remember, an allograft is a transplant between genetically non-identical individuals of the same species.

Cardiac Assist Intra-aortic device (33967-33974)
Insertion and removal codes Ventricular assist device ( ) Extracorporeal Intracorporeal Insertion removal Percutaneous assist device ( ) Arterial only Arterial and venous with transseptal puncture Removal Repositioning Cardiac assist devices are mechanical pumps that can be implanted to support weak hearts. The codes include intra-aortic balloon assist devices, extracorporeal and intracorporeal single and biventricular devices, and now ventricular devices that can be inserted percutaneously. The codes in this section also include the removal of the cardiac devices.

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 The section on Arteries/Veins contains multiple codes and completes this section of CPT®. An aneurysm is dilation of an artery or cardiac chamber usually due to an acquired or congenital weakness of the wall of the vessel or chamber. Abdominal aortic aneurysm is a serious condition presenting as an abdominal mass, severe abdominal or back pain, or if the aneurysm ruptures, it is a serious medical emergency with mortality over 80 percent. With this condition, the lower portion of the major artery of the body, the aorta, swells and can be several times normal size.

Aneurysms Endovascular Repair of Abdominal Aortic Aneurysm
( ) Codes describe open femoral or iliac artery exposure, device manipulation and deployment, and closure of the arteriostomy sites. Read guidelines for bundled and additional procedures Endovascular Repair of Iliac Aneurysm (34900) Fenestrated Endovascular Repair of the Visceral and Infrarenal Aorta ( ) Surgical repair includes endoprosthesis or open treatment replacement with a prosthetic graft. Other large vessels can present with aneurysms, such as the iliac artery.

Aneurysms Direct Repair of Aneurysm or Excision (Partial or Total) and Graft Insertion for Aneurysm, Pseudoaneurysm, Ruptured Aneurysm, and Associated Occlusive Disease ( ) Separate codes for aneurysm repair and ruptured aneurysm repair There are many codes in CPT® for direct repairs of aneurysms based on the site and on whether the aneurysm has ruptured.

Thromboendarterectomy (35301-35390)
Removal of thrombus and inner lining of vessel Includes patch graft if performed Reported by site 35390, Reoperation, carotid, thromboendarterectomy, more than 1 month after original operation. Use in conjunction with 35301 Thrombi block major vessels. A thrombus is a clot in the cardiovascular system formed from blood components. The removal or thromboendarterectomy is a major surgical procedure. Note the add-on code 35390, for reoperation for carotid endarterectomy, which is used for surgery performed more than one month after the original operation.

Transluminal Angioplasty
Open Renal or other visceral artery Aortic Brachiocephalic trunk or branches, each vessel Venous Percutaneous Renal or visceral artery Code also for catheter placement and radiologic S&I Transluminal angioplasty can be either with an open incision or percutaneous. Angioplasty is a technique used to mechanically open an obstructed blood vessel. A balloon catheter is threaded into the narrowed section, and then it is inflated. The balloon crushes fatty deposits, opening up the blood vessel, and then it is deflated and withdrawn. Note, catheter placement and radiological supervision and interpretation are reported separately.

Transluminal Angioplasty
From a right femoral artery access the catheter was advanced into the aorta. Transluminal aortic angioplasty was performed. 36200 Placement of catheter into aorta Angioplasty aorta Look in the CPT® index for Transluminal/Angioplasty/Arterial/Radiological Supervision 37246, 37247 Catheter placement and S&I will be covered later. This slide shows the coding for transluminal aortic angioplasty. Note that there are codes for nonselective placement of the catheter, the angioplasty, and the radiological supervision and interpretation. The catheter placement and radiological codes will be covered later in this chapter.

Bypass Grafts Non-coronary vessels Vein (35500-35572)
In-situ vein ( ) Vein is left in native location Other than vein ( ) Composite Grafts ( ) Code by type/location Bypass graft and composite grafts codes list various procedures to restore blood flow to several body areas. This includes an autograft, which is tissue or organ transferred by grafting into a new position in the body of the same individual using a vein, or artery. Synonyms include autogenous, and autologous. Synthetic grafts may also be used.

Vascular Injection Procedures Endovascular Revascularization
Vascular Injection Procedures and Endovascular Revascularization will be discussed in the Interventional Cardiology/Radiology Section (IVR) Vascular Injection Procedures and Endovascular Revascularization will be discussed in the Interventional Cardiology/Radiology section.

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, etc.) Tunneled or not With pump or port Patient age See CVAP Table in CPT® This section of CPT® contains The Central Venous Access Procedures Table. The medical term, “Central Line” describes the placement of catheters to administer parenteral nutrition, medications, or measure central venous pressure (CVP). Put simply, these access lines are very serious IVs used in very sick patients. They are placed into the right or left subclavian, jugular, femoral veins, or the inferior vena cava. The tip of the catheter or device must terminate in the subclavian, brachiocephalic, or iliac vein, the superior or inferior vena cava, or the right atrium. There are also codes to report removal and repair of these devices.

CPT® Hemodialysis ( ) Dialysis Circuit ( ) Peripheral segment – begins at the arterial anastomosis and extends to the central dialysis segment. Central segment – includes all draining of veins central to the peripheral dialysis segment. Dialysis is the removing of blood from the patient’s body, cleansing it to replace and supplement the function of the kidneys and returning it back to the patient’s body. To accommodate patients needing dialysis, several procedures are helpful. Hemodialysis is filtration of the blood to replace the vital function of the kidneys. It requires access to the circulation, which can involve a cannula, arteriovenous anastomosis or fistula, or shunt. The dialysis circuit is designed for easy and repetitive access to blood vessels to perform dialysis. CPT separates the dialysis circuit into two segments; peripheral and central. Coding for this section is based on progressive hierarchies. Each more intensive service includes the procedures performed in the less intensive services. Therefore, only one code is reported for services provided in a dialysis circuit. Ultrasound guidance for puncture of the dialysis circuit access is not typically performed and is not included in Note to Instructor: There are definitions in the guidelines. Please go over these definitions with your students.

CPT® Portal Decompression (37140-37183)
Treat hypertension/occlusion of portal vein TIPS (37182, 37183) diverts blood from the portal vein to the hepatic vein TIPS = transvenous intrahepatic portosystemic shunt(s) Transcatheter Procedures Removal of clot (thrombectomy) Arterial Thrombectomy ( ) Venous Thrombectomy ( ) Other Procedures ( ) Foreign body retrieval, placement vena cava filter, transcatheter embolization, stent placement, etc. Portal decompression is performed to treat portal hypertension due to hepatic venous outflow obstruction. A transjugular intrahepatic portosystemic shunt (TIPS) is a percutaneously created connection within the liver between the portal and systemic circulations. There are also Transcatheter Procedures for arterial and venous thrombectomy, and other catheter procedures that are very specific, such as insertion and removal of vena cava filters, embolization of tumors or fibroids, and stent placement.

Interventional Procedures
Interventional Cardiology/Radiology Branch of medicine Minimally invasive techniques using imaging guidance to diagnose and treat diseases Catheter is threaded into vessels to perform procedure(s) Multiple codes may be used from different sections of CPT® (eg, Surgery, Radiology, and Medicine) Next we will discuss Interventional Procedures. Interventional Cardiology/Radiology is a branch of medicine, which uses minimally invasive techniques to diagnosis and treat diseases. Using fluoroscopic, ultrasound or other guidance, a catheter is threaded into vessels to perform procedures. To report these procedures in full, you may need to report multiple codes from different sections of CPT®, such as Surgery, Radiology, and Medicine. We will discuss each separately, and use two part examples.

Vascular Injection Procedures (36000-36660)
Vascular Injections include the following: Local anesthesia Introduction of the needle or intracatheter Injection of contrast material All pre- and post-injection patient care Closure of vascular access The guidelines for vascular access are listed for you on the slides. It is necessary to consult the Radiology chapter of CPT® for radiological supervision and interpretation for these procedures. This section includes guidelines for diagnostic studies of arteriovenous (AV) shunts for dialysis.

Vascular Injection Procedures
Intravenous Nonselective – venography, superior or inferior vena cava Selective First order Second order Intra-Arterial - Intra-Aortic Procedures Nonselective Vascular injection procedures report the placement of needles or catheters, referred to as intracatheter, for various indications, including nonselective and selective catheter placement for arteries and veins. Refer to CPT® Appendix L, Vascular Families for first, second, and third order and beyond branches based on a starting point in the aorta.

Five Vascular Families: Systemic Arterial Systemic Venous Pulmonary Portal Lymphatic Note when reading your CPT® codebook there are codes for the five vascular families – systemic arterial, systemic venous, pulmonary, portal, and lymphatic.

Non-Selective catheterization Catheter is placed directly into an arterial or venous vessel and not moved or manipulated further (36100, 36120, 36140) Or the catheter is moved only into the aorta from any approach (36200) Introduction of needle or intracatheter, aortic, translumber (36160) Nonselective catheterization indicates the catheter is placed directly into an arterial or venous vessel and it is not moved or manipulated further, such as moving a catheter into the aorta from any approach.

Selective Catheterization Catheter is moved, manipulated or guided into a part of the arterial/venous system other than the aorta or the vessel punctured. The exact code used depends on how many branches the catheter must be guided through before it reaches the ultimate injection site. See CPT® Appendix L Vascular Families for first, second, third order, and beyond third order branches based on a starting point in the aorta. Selective catheterization indicates the catheter is moved, manipulated or guided into a part of the arterial or venous system other than the aorta or the vessel punctured. The code selection depends on the highest final placement of the catheter in a vascular family.

Selective Catheterization
Vascular Families Primary (first turn off the main highway [aorta]) First-order vessels (eg, innominate/brachiocephalic artery, left common carotid, left subclavian) Secondary (second turn off the main highway [aorta]) Second-order vessels, (eg, right common carotid artery, left external carotid, left vertebral [aorta]) Tertiary (third turn off the main highway [aorta]) Third-order vessels, (eg, right external carotid artery, right vertebral) The codes for vascular families are chosen based on first order, second order, or tertiary (third level) of selective catheterization.

This illustration shows the order of vessels based on the starting point being the aorta.

Selective Catheterization
Vascular Access Rules From a single access catheter puncture site, selective catheterization takes precedence in coding over the nonselective catheterization. Only report highest order of one family. If other 2nd or 3rd levels catheterized in same family, use add-on code Code for each vascular family accessed Code for each vascular access Above diaphragm ( ) Additional second and/or third order use add-on code 36218 Below diaphragm ( ) Additional second and/or third order use add-on code 36248 Pulmonary angiography involves the right and left pulmonary arteries representing two vascular families The vascular access rules are listed for you. Selective catheterization takes precedence in coding over the nonselective catheterization. Only report the highest order of one family. If other second or third order levels are catheterized in the same family, use the add-on code. Code for each vascular family accessed. Codes are based on above the diaphragm and below the diaphragm. Pulmonary angiography involves the right and left pulmonary arteries representing two families.

Selective Catheterization Part I (Surgical)
From a right femoral access, code the selective catheterization of the common hepatic artery. Check Appendix L for the vascular family order starting from the aorta From a right femoral access, code selective catheterization of the left brachial, and the left internal thoracic arteries. Check Appendix L with the starting point of the aorta. Modifier 59 indicates separate vascular family , From a right femoral access, code the selective catheterization of the right internal thoracic, and the right ulnar artery , 36218 Here you see examples of selective catheterization, Part 1 (Surgical) of interventional cardiology/radiology.

Selective Catheterization Part 2 – Vascular Procedures Radiology
Use when physician provides both surgical and radiology portion of an interventional service Modifier 26 Professional component may be required Use modifier 26 when services performed in a facility/hospital setting or when equipment not owned by provider Radiology Guidelines Do not use diagnostic angiography radiologic supervision and interpretation (S&I) with interventional procedures for: Roadmapping (taking a look) Vessel measurement Post-angioplasty/stent angiography follow-up Intervention procedures which include S&I Next is Part 2 (Radiology) of interventional cardiology/radiology and guidelines which instruct you not to use diagnostic angiography S&I with interventional procedures.

Selective Catheterization Part 2 – Vascular Procedures Radiology
Report diagnostic interventional procedures when: Performed at separate setting No prior angiography study is available Prior study is available, but patient’s condition has changed There is inadequate visualization of anatomy and/or pathology Do report diagnostic interventional procedures when they are performed at a separate setting, when no prior angiography study is available, and when the patient’s condition has changed, or there is inadequate visualization of anatomy and/or pathology .

Selective Catheterization Part I (Surgical) & Part 2 (Radiological)
Part 1 (surgical) From a right femoral access a catheter was placed in the aorta (nonselective 36200) and aortography is performed. Next the catheter is manipulated into the celiac artery and angiography is performed. Check Appendix L. This is first order (36245). Code is dropped, because you only code to the highest level of catheter placement. Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family Part 2 (Radiology) The celiac artery is a visceral artery. Look in the CPT index for Angiogram/Abdominal and you will see a range of codes. 75726 Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and interpretation Modifier 26 is required for the professional service. The aortography is bundled. 36245, Here are examples of use of both the surgical and radiology codes.

Selective Catheterization Part I (Surgical) & Part 2 (Radiological)
Take the previous example of the diagnostic angiography of the celiac artery. During the study a stenosis of 85% is found and the decision is made to insert a stent. Look in the CPT® index for Transcatheter/Placement/Intravascular Stent 0075T-0076T, , , Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed, initial artery Part 1 (surgical) 37236 Part 2 (Radiological) Radiological supervision and interpretation are included in the surgical code 37236, 36245, Modifier 59 is needed to show that this angiography was diagnostic and not included in the stent procedure. See the examples in your text for interventional surgical and radiological codes. You will see that newer interventional codes such as angiography of the renal arteries and diagnostic studies of the cervicocerebral arteries include the selective or nonselective catheterization, the injection of contrast, and the radiological supervision and interpretation.

Diagnostic Studies of Cervicocerebral Arteries (36221-36228)
Diagnostic studies of the cervicocerebral arteries include: Nonselective and selective arterial catheterization Diagnostic imaging of the aortic arch, carotid, and vertebral arteries Contrast injection Closure of arteriotomy by pressure or closure device Interventional procedures during the same session are coded separately Diagnostic Studies of Cervicocerebral Arteries codes describe nonselective and selective arterial placement and diagnostic imaging of the aortic arch, carotid, and vertebral arteries. Codes include the work of accessing the vessel, placement of catheter(s), contrast injection(s), and closure of the arteriotomy by pressure, or application of an arterial closure device. Interventional procedures performed during the same session may be reported separately. Radiographic supervision and interpretation are separately reported with

Selective catheter placement, external carotid artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure) (Use in conjunction with 36222, 36223, or 36224) (Do not report in conjunction with for ipsilateral services) Selective catheter placement, each intracranial branch of the internal carotid or vertebral arteries, unilateral, with angiography of the selected vessel circulation and all associated radiological supervision and interpretation (eg, middle cerebral artery, posterior inferior cerebellar artery) (List separately in addition to code for primary procedure) (Use in conjunction with 36223, 36224, or 36226) (Do not report more than twice per side) This group of codes contains two add-on codes. Code is used for selective catheterization of the external carotid artery, and is used for selective catheterization of each intracranial branch of the internal carotid or vertebral arteries during diagnostic studies of the cervicocerebral arteries.

Do not report as part of diagnostic angiography of the extracranial and intracranial cervicocerebral vessels. Report or for 3D rendering when performed in conjunction with Report for ultrasound guidance for vascular access when performed in conjunction with The codes in the surgery section do not have a professional and technical component. Cervicocerebral diagnostic studies notes give additional tips for 3D rendering and ultrasound guidance, which can be reported in addition to the diagnostic studies.

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) Atherectomy Stent placement Angioplasty (lowest) The next section includes Endovascular Revascularization (Open or Percutaneous, Transcatheter). Therapies or treatments for revascularization include transluminal angioplasty, atherectomy, and placement of stents. These procedures are applied in three arterial areas: iliac (excluding atherectomy), femoral/popliteal, and tibial/peroneal.

Bundled to Endovascular Revascularization (37220-37235)
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 These procedures include the work of accessing and selectively catheterizing the vessel, traversing the lesion, radiological supervision, and interpretation directly related to the intervention(s) performed, embolic protection if used, closure of the arteriotomy by pressure and application of an arterial closure device or standard closure of the puncture by suture, and imaging performed to document completion of the intervention in addition to the intervention performed.

Iliac vascular territory codes do not include atherectomy Use Category III codes 0234T-0238T for atherectomy in the supra-inguinal vessels (iliacs, visceral, aorta, renal, brachiocephalic) Codes include radiological supervision and interpretation Codes do not include: Selective catheterization of vessel Traversing lesion Embolic protection, if used Other intervention used to treat the same or other vessels Closure of arteriotomy by any method The iliac territory, with three separately billable vessels (the internal iliac, external iliac, and common iliac arteries) allows separate billing of atherectomy, in addition to an angioplasty or stent placement. This is because atherectomy in the supra-inguinal vessels (iliacs, visceral, aorta, renal, and brachiocephalic) utilize Category III CPT® codes 0234T-0238T, which do not have the same bundling issues as infra-inguinal lower extremity revascularization codes. These Category III codes do not include accessing and selectively catheterizing the vessel, traversing the lesion, embolic protection if used, other intervention used to treat the same or other vessels, or closure of the arteriotomy by any method. CPT® codes Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty and Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty describe initial and additional iliac angioplasty; therefore, if angioplasty is the only intervention performed in the iliac arteries on one extremity, these codes are used (one for the initial vessel, and up to two additional codes if two additional vessel—not lesion—angioplasties were performed). If iliac stent placement is performed additionally in one vessel, (initial angioplasty) is replaced by Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed, which bundles angioplasty in the same vessel. Any additional iliac angioplasty procedures in additional iliac arteries are coded with add-on code

From a left femoral access, a stent was placed and atherectomy was performed in the right common iliac. 0238T Transluminal peripheral atherectomy, open or percutaneous, including S&I; iliac artery, each vessel Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel, with transluminal stent placement(s) 36245 is not included in 0238T; however, it is not reported, because the same access is used for If atherectomy is performed instead of stent placement, 0238T Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; iliac artery, each vessel is coded in addition to code Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty for the initial angioplasty. If atherectomy and stent placement are performed in the common iliac artery, codes 0238T and Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed are used. If the procedure was performed from a left femoral access, then must be reported for 0238T, because access is not included in 0238T. Modifier 59 is needed to show that this is separate from 37221, which includes access. Medicare requires modifier XU to show it is a distinct, non-overlapping service instead of modifier 59. The supra-inguinal atherectomy codes are coded in addition to any other intervention in the same vessel at the same lesion site; thus, you may bill angioplasty, atherectomy, and stent placement in the aorta or a renal, visceral, brachiocephalic artery, depending on documentation.

From a right femoral artery access, report stent placement in left superficial femoral artery, and angioplasty of the left popliteal artery. Revascularization, endovascular, open or percutaneous, femoral, popliteal, unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed. The entire femoral/popliteal territory is considered a single vessel for revascularization procedures. The femoral/popliteal territory is unusual compared to the other two territories, because all four vessels in this territory are considered a single vessel for coding purposes. All interventions performed in the common femoral, profunda femoral, superficial femoral, and popliteal arteries are described by a single code. The hierarchy still applies: atherectomy supersedes stent placement , which supersedes angioplasty. Stent placement may occur at two levels: Code Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed describes stent placement alone (with or without angioplasty), while Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed describes stent placement with atherectomy (with or without angioplasty). For the femoral/popliteal territory, one should consider all treatments in all vessels as treatment in a single vessel. For all interventions performed in this territory, only one code between and is submitted, regardless of the number of interventions performed in these four vessels. There are no initial or additional revascularization codes for the femoral/popliteal territory; if an angioplasty is performed in the profunda femoral, an atherectomy is performed in the superficial femoral, and a stent is placed in the popliteal artery, report stent placement with atherectomy, with or without angioplasty.

From a right femoral artery access, report the stenting of the right peroneal trunk, and angioplasty of the dorsalis pedis artery and posterior tibial artery. 37230 Revascularization, endovascular , open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) x2 each additional vessel; with transluminal angioplasty The tibial/peroneal codes allow for more than one vessel to be described and coded. Three separately billable vessels are recognized: the anterior tibial, posterior tibial, and peroneal arteries. The tibial/peroneal trunk is considered part of any distal intervention performed in the posterior tibial or peroneal arteries, although the dorsalis pedis artery is considered a continuation of the anterior tibial artery, and the medial malleolar artery is considered a continuation of the posterior tibial artery. Here again, the hierarchy applies: stent placement with atherectomy supersedes atherectomy without, stent placement which supersedes stent placement, which supersedes angioplasty alone (remember, angioplasty is included in all interventions, if performed). Code the highest vessel intervention as the initial intervention in this territory, and any other vessel interventions as additional tibial/peroneal interventions. Codes describe initial interventions and add-on codes describe additional interventions in the other two tibial/peroneal arteries. Remember, each territory is coded separately (except bridging lesions) with initial and additional revascularizations in each territory as appropriate (the femoral/popliteal territory does not use initial/additional designations). For instance, you can have an initial iliac revascularization and an initial tibial/peroneal revascularization. If you perform a bilateral procedure in the lower extremities, start the coding all over again for the opposite leg with initial revascularization codes for both sides. As already noted, all 16 lower extremity revascularization codes, , include angioplasty, if performed. Angioplasty, which is balloon dilation of a stenosis or occlusion, can be performed with a compliant, non-compliant, cutting, or cryo- balloon. Atherectomy, which is the removal of atheroma, is performed with rotational, front-cutting, side-cutting, and photoablation (laser) devices. Stent placement utilizes self-deploying, balloon expandable, covered (stent grafts), and drug-eluting stents. Always bill the initial vessel intervention at the highest level of intervention performed within a single territory. If a separate intervention is performed within a different territory, start coding all over again with an initial intervention for that territory, based on hierarchy guidelines (stent placement with atherectomy, followed by atherectomy,, followed by stent placement,, followed by angioplasty).

Guidelines for treatment of one extremity Report initial vessel intervention at the highest level of intervention Hierarchy from highest to lowest: stent placement with atherectomy, stent placement, atherectomy, angioplasty Report initial vessel intervention for each intervention performed within a different territory Intervention of additional vessels within a territory are reported with add-on codes Bridging lesions are considered a single-vessel intervention, even if the bridging lesion extends from one territory into another. Diagnostic imaging is separately billable. Other interventions such as IVUS, thrombolysis, thrombectomy, and embolization are separately billable. These guidelines are for treatment of one extremity. If performing intervention on both legs, start coding all over again on the opposite leg. You may need modifier 59 Distinct procedural service (per CPT® instruction), or modifier 50 Bilateral procedure (per the Physician Fee Schedule Relative Value File), as appropriate, to alert the payer intervention occurred in both extremities. Bridging lesions still are considered a single-vessel intervention, even if the bridging lesion extends from one territory into another. You still need to have a hemodynamically significant vessel stenosis to meet medical necessity to code for these interventions. For bifurcating lesions distal to the common iliac origins, which require therapy of two distinct branches of the iliac or tibial/peroneal vascular territories, a primary code and an add-on code are used to describe the intervention. Diagnostic imaging remains separately billable. The imaging must be truly diagnostic, however, and not performed just for “confirmation” of a lesion or “guidance” for an intervention. When performed to measure vessel size, localize a lesion, follow-up an intervention, or guide the procedure, imaging is bundled. Other interventions in these lower extremity vessels treated with angioplasty, atherectomy, and/or stent placement are separately billable. These include IVUS, thrombolysis, thrombectomy, and embolization.

Medicine Section Cardiovascular (92920-93799)
Therapeutic services and procedures Other Therapeutic Services and Procedures Coronary 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 The next large group of cardiovascular listings in CPT® is in the Medicine Section, the series of codes. The Cardiovascular subsection of the Medicine Section in CPT® is divided into several headings. Cardiac procedures described are invasive or minimally invasive, and include procedures such as cardiac catheterization and percutaneous transluminal coronary balloon angioplasty (PTCA). They are listed in this section and not in the Surgery Chapter, because they are not classified as open surgical procedures. Therapeutic procedures describe coronary thrombolysis, placement of intracoronary stents, balloon angioplasty, balloon valvuloplasty, atrial septectomy, and coronary atherectomies. These therapeutic procedures are considered invasive and are performed using a percutaneous catheter.

Other Therapeutic Services and Procedures
Cardiopulmonary resuscitation Includes defibrillation Includes treatment to the pulmonary system Not 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 (elective) Code reports cardiopulmonary resuscitation (CPR) and includes defibrillation. The code also includes treatment to the pulmonary system. Fibrillation is the rapid contraction or twitching of muscular fibers – in the instance of the heart, this means ineffective pumping. Defibrillation is shocking of the cardiac muscle to arrest fibrillation with restoration of the normal rhythm of the heart and is used to treat an atrial or ventricular arrhythmia. Defibrillation may be administered during cardiac resuscitation, critical care, following open heart surgery, during cardiac surgery, or during an electrophysiological procedure. Defibrillation is considered inclusive in these cases. Cardiopulmonary resuscitation is not considered a component of critical care services, and may be reported in addition to codes or Cardioversion is not the same as defibrillation. Cardioversion is a brief procedure where an electrical shock is delivered to the heart to convert an abnormal heart rhythm back to a normal rhythm. Defibrillation is performed in emergent situations to convert the heart from a life- threatening cardiac rhythm back to a normal rhythm. Conditions treated with cardioversion include paroxysmal supraventricular tachycardia (PAT) or ventricular tachycardia, atrial fibrillation or flutters. A physician administers an electronic shock with a defibrillator to the patient’s chest to correct the arrhythmia.

Cardiovascular Therapeutic Services and Procedures (92920-92979)
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 Atherectomy—procedure to remove plaque from arteries The critical role of the coronary vessels has been stressed; coronary thrombolysis is dissolving of a blockage by a thrombus clot in one of these vessels. Thrombolytic drugs can be selectively infused into the coronary arteries, or they can be given by intravenous infusion to dissolve the clot and open the vessel. A coronary stent is a wire metal mesh tube placed inside an artery to hold the vessel open. Angioplasty procedures are performed to dilate and open a blocked artery. Percutaneous balloon angioplasty is done with a thin catheter inserted into the artery, typically the femoral artery, and then advanced to the point of blockage. A balloon at the end of the catheter is inflated and deflated intermittently to relieve the blockage. These procedures are performed with careful monitoring and visualization with radiology. Valvuloplasty is a similar procedure to dilate a stenosed valve.

Cardiovascular Therapeutic Services and Procedures (92920-92979)
Coronary artery therapeutic procedure guidelines: Three coronary arteries are recognized and ramus intermedius arteries Right coronary (RC) Left anterior descending (LD) Left circumflex (LC) Only one procedure reported per coronary vessel Access through a coronary bypass graft is reported separately Each bypass graft represents a coronary vessel Each sequential bypass graft with more than one distal anastomosis represents only on graft Up to 2 coronary artery branches of LD (diagonals), LC (marginals), and RC (posterior descending, posterolaterals) are recognized Report with add-on codes Hierarchy from highest to lowest value for percutaneous interventions: Atherectomy Stent placement Angioplasty HCPCS level II modifiers RC, LC, and LD are appropriate for coronary artery vessels for percutaneous coronary interventions (PCI). Report one base procedure per coronary vessel (LC, LD, RC). Each bypass graft represents a coronary vessel as well as ramus intermedius arteries. Up to two coronary artery branches of the left anterior descending (diagonals), left circumflex (marginals), and right (posterior descending, posterolaterals) coronary arteries are recognized. Only one base code may be reported for revascularization of a major coronary artery and its recognized branches. Only one base code should be reported for revascularization of a coronary artery bypass graft, its subtended coronary artery, and recognized branches of the subtended coronary artery. The hierarchy for the initial procedure from highest to lowest is atherectomy, stent placement, and lastly angioplasty. PCI performed during the same session in additional recognized branches of the target vessels should be reported with add-on codes ranked from highest to lowest.

Coronary Therapeutic Services and Procedures (92920-92979)
Percutaneous coronary intervention (PCI) include: Accessing, selective catheterization of vessel Traversing lesion Radiologic supervision and interpretation related to intervention(s) Closure of arteriotomy Imaging to document completion Do not report diagnostic cardiac catheterization codes ( ) and injection procedures ( ) with ) unless diagnostic cardiac catheterization is required prior to the intervention service. See guidelines in CPT®. Read all the instructions in CPT® for percutaneous coronary intervention.

If a single lesion extends from one major coronary artery to another target vessel, but can be revascularized with a single intervention bridging the two vessels, report a single code. Example: Left main coronary lesion extends into the proximal left circumflex and a single stent is placed across the entire lesion 92928-LC Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch When a PCI involves a single lesion which extends from one major coronary artery to another target vessel, but it can be revascularized with a single intervention, report a single code.

When a bifurcation is treated, PCI is reported for both vessels treated. Example: A bifurcation lesion involving the left anterior descending artery and the first diagonal artery is treated by stenting both vessels. 92928-LD, LD When a PCI involves treatment for a bifurcation, report both vessels treated.

Example: Angioplasty in the right coronary and stent placement in the left circumflex, with atherectomy in the left anterior descending coronary artery. Intravascular ultrasound (IVUS) was used in each vessel. 92924-LD, LC, RC, 92978, 92979, Now you can see an example of the coding for angioplasty in the right coronary and stent placement in the left circumflex, with atherectomy in the left anterior descending coronary artery. Intravascular ultrasound (IVUS) was used in each vessel.

Monitoring Heart Activity
Cardiography (93000 – 93042) Codes for professional component, technical component, and global Implantable and Wearable Cardiac Device Evaluations ( ) For the 90-day period, do not report for less than 30 days For the 30-day period, do not report less than 10 days Cardiac Stress Tests Activity or pharmaceutical Codes for global, technical, and professional components. There are several codes to describe methods used to record heart activity. Read the code descriptions carefully, because some of these CPT® codes describe the global procedure, while other codes describe the physician component (modifier 26) or the technical component (modifier TC) portion of the procedure. Cardiography codes are used to report electrocardiogram (EKG or ECG) procedures. A provider who owns the equipment, employs the technician, and interprets and prepares the report of the EKG can report If a physician provides the interpretation and report, but the hospital performs the EKG, for the interpretation and report only is reported. If only the technical component is performed, report Mentioned earlier, the electrical activity of the heart can be monitored externally with an EKG. “Leads”, or electrodes, are placed on the skin in specific areas of the chest. Often times the specificity of the test is indicated by the number of leads or electrodes used. After the test is performed, it also must be interpreted. The next section, , lists codes for reporting more long-term monitoring, including time periods from several hours to days. There are also Implantable and Wearable Cardiac Device Evaluations that can include a single lead (electrode) or multiple leads. It should be noted: codes are used no more than once every 90 days and are not used if the monitoring period is less than 30 days. There are lengthy instructions in this section that should be read. Cardiovascular services for remote device interrogation have become the standard of care. These implantable cardiovascular monitor systems assist physicians in managing a non-rhythm-related cardiac condition. You will need to identify the type of device evaluated, what type of system is being evaluated (pacemaker, implantable defibrillator, single or dual lead); whether the evaluation is in person or remote, and the length of time being evaluated. A cardiovascular, or cardiac, stress test records the electrical events of the heart while performing stressful activity, such as running; stress can also be induced with medications. To approximate angina, a drug, Ergonovine, which induces narrowing of arteries, is given. The result is spasm of the coronary artery, the patient is monitored, and the reaction is observed and recorded. Some coders find underlining or highlighting key words can help avoid unbundling or reporting an inappropriate component in this section.

Echocardiography (93303-93355) 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 Transthoracic (TTE) or esophageal (TEE) Note congenital echo Complete or limited study Echocardiography reports a diagnostic ultrasound of the heart; this imaging obtains information regarding the heart and great vessels. Read the instructions at the beginning of this section. Doppler is a diagnostic instrument that emits an ultrasound beam into the body: This signal is reflected from moving structures (called “Doppler effect”). It has diagnostic value in cardiac and peripheral vascular disease. An echocardiogram may be used to assess various cardiac conditions, such as valvular disorders, pericardial effusion, cardiac hypertrophy, or heart failure. It is amazing to think a small probe can be passed through the mouth and down the throat (transesophageal) to visualize the heart and great vessels. Echocardiography is usually performed with a transducer over the chest along the left or right sternal border in the region of the cardiac apex, at the suprasternal notch, or over the subcostal region. The type of ultrasound and transducer used is identified in the code description. There are also codes in the Radiology section of CPT® describing cardiac ultrasonic guidance. M-mode recording, Doppler echocardiography and color flow mapping are typically performed with echocardiography to enhance visualization and interpretation. M-mode echocardiography is used to measure chamber dimensions and to establish the timing of events such as valve or cardiac wall motion. Doppler echocardiography records the direction and velocity of blood flow through the heart chambers. Color-flow mapping allows images of the blood flow to be displayed and abnormalities can be visualized. When a stress echocardiogram is performed with a complete cardiovascular stress test, use When only the professional components of a complete stress test and a stress echocardiogram are provided, such as in a facility setting, by the same physician, use with modifier 26.

Cardiac Catheterizations (93451-93583)
Most common access point – femoral artery Right or left heart catheterization? Catheter insertion, injection(s), and imaging are combined in one code Cardiac Catheterization coding can be challenging. Cardiac catheterizations include multiple components. The catheter insertion, injection(s) and imaging code(s) are combined into one code. There is a Cardiac Catheterization Codes Table in CPT®.

There are two code families for cardiac catheterization: Congenital heart disease All other conditions Anomalous coronary arteries, patent foramen ovale, mitral valve prolapse, and bicuspid aortic valve are to be reported with , There are two basic groups for cardiac catheterization: one for congenital heart disease, and one for all other conditions. Cardiac catheterization is an invasive diagnostic procedure. A catheter is passed through a peripheral blood vessel into the heart. It is possible to take blood samples to evaluate oxygen content; blood flow and pressures in the heart are measured. This amazing technology can be used to evaluate valve problems, and visualize cardiac, aortic, pulmonary, and coronary artery anomalies.

For cardiac catheterization for congenital anomalies, see When contrast injection(s) are performed in conjunction with cardiac catheterization for congenital anomalies, see Cardiac catheterization ( ) includes all roadmapping angiography in order to place the catheters, including any injections and imaging supervision, interpretation, and report. It does not include contrast injection(s) and imaging supervision, interpretation and report for imaging that is separately identified by specific procedure code(s). For aortography, use For pulmonary angiography, use Cardiac catheterization procedures have a technical and professional component Add-on codes for injection procedures are professional services; therefore, no modifier The femoral artery is the most common access point for cardiac catheterizations, although the heart can also be accessed through the brachial or axillary arteries as well. Once the catheter is in the femoral artery, it is advanced into a branch artery or cardiac chamber. It is important to know if it is a right or left heart catheterization, and how it is accessed to determine the appropriate catheterization code. Angiography is injection of a contrast material into the blood vessel or chamber with imaging to visualize the location and anatomy. A physician performs both the cardiac catheterization and the supervision and interpretation. In some instances, modifier 26 will be required when services are performed in a hospital or cardiac cath lab. A Swan-Ganz catheter is a cardiac catheter used for continuous monitoring of the heart activity of critically ill patients. Placement is reported by the provider performing the procedure: This may be an anesthesiologist.

From a right femoral access, right and left cardiac catheterization was performed, with coronary angiography, and angiography of bypassed vessels, with right and left ventriculography. Injection procedure was performed to view the aortic cuff for possible aneurysm. Report the physician service. , 93566, 93567 This slide shows you how to code a right and left heart catheterization with coronary angiography, with angiography of bypass vessels, with right and left ventriculography. An injection procedure was performed to view the aortic cuff for a possible aneurysm. The add-on codes do not require a modifier, because they are professional services only

Cardiac Anomalies Septal Defect – hole in the septum (or wall) of the heart separating the atria and ventricles Repair of Septal Defect Transcatheter Closure Septal defects were described previously; you can think of them as holes in the walls of the pump separating the atria and ventricles. These defects make the pump much less efficient. Septal defects can be intra-atrial or intraventricular. For repair of septal defects, transcatheter closure devices provide an option to open heart surgery; this is performed in a catheterization laboratory or “cath lab.” The exact mode of deployment varies according to the device and anomaly.

Intracardiac Electrophysiological Procedures/Studies
Percutaneous Indications - Cardiac arrhythmias causing: Palpitations—irregular heart beats Syncope—loss of consciousness Cardiac arrest Intracardiac Electrophysiological procedures/studies is next. These services are both diagnostic and therapeutic. Percutaneous, they are less invasive than surgical procedures. Electrode catheters are placed within the heart to evaluate the heart’s electrical system and provide pacing or ablation services. There are introductory notes with definitions and coding tips; review this information in CPT®. The SA node initiates the cardiac cycle, and the electrical impulse travels to the atria, causing contraction. Blood is forced by this contraction into the ventricles. At the same time, the AV node depolarizes, and the impulse follows the bundle of His. Next, the electrical impulses travel to the right and left bundle branches to be distributed over the medial surface stimulating the Purkinje fibers located in the apex of the heart. Stimulation results in ventricular contraction, and blood is forced to the lungs (from the right ventricle) and to the body (from the left ventricle). Electrophysiological testing is indicated when cardiac arrhythmias cause symptoms of palpitations, syncope or cardiac arrest. Palpitation is irregular heartbeats; syncope refers to loss of consciousness or “blacking out.” Ventricular arrhythmias (tachycardia or fibrillation) may cause sudden death. Electrophysiological procedures are used during the initial diagnosis and therapy. Anti-arrhythmic drugs may be given to control arrhythmias. Sometimes during an electrophysiologic study (or EPS), there is an attempt to induce an arrhythmia. This induction is performed through the catheters placed in at least one of the heart chambers for recording and pacing. In this process, stimulation may be performed in any cardiac chamber until the clinical arrhythmia has been induced or until the protocol has been completed. Termination of arrhythmias by pacing methods or direct counter shock during EPS is considered an inclusive procedural component and not reported separately.

Intracardiac Electrophysiological Procedures/Studies
There are codes for: Diagnostic electrophysiologic studies Mapping Ablation Diagnostic electrophysiologic studies with ablation during the same session There are codes in this section that combine the diagnostic electrophysiologic study, mapping, and ablation in one session .

Peripheral Arterial Disease (PAD)
Rehabilitation is reported per session Narrowing or blockage of the arteries in the legs Symptoms: Cramping Aching Numbness Peripheral Arterial Disease Rehabilitation reports rehabilitation per session, typically lasting minutes each. Peripheral arterial disease (PAD, also called peripheral artery disease) is a narrowing or blockage of the arteries in the extremities, usually the legs. Patients can experience symptoms, such as cramping, aching, or numbness. Rehabilitation involves a monitored exercise plan. When new symptoms arise during the course of rehabilitation, the physician may need to intervene and review the plan of treatment.

Noninvasive Vascular Diagnostic Studies (93880-93990)
Cerebrovascular Arterial Studies Extremity Arterial Studies (Including Digits) Extremity Venous Studies (Including Digits) Visceral and Penile Vascular Studies Extremity Arterial-Venous Studies Most of the studies in this section are considered bilateral. If a unilateral study is performed, use modifier describes a complete bilateral study of lower extremity arteries Noninvasive Vascular Diagnostic Studies describe bioimpedance, plethysmography, and electronic analysis of pacemaker systems, initial setup and programming of wearable defibrillator systems, thermograms, and blood pressure monitoring. This is another section that requires close reading of the descriptions to know which codes include the professional, technical or global components.

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 Specific modifiers useful for the Cardiovascular subsections have been mentioned in the previous discussion. Others that are useful include: 80 Assistant surgeon is used when an assistant performs graft procurement for coronary bypass grafting, such as with Modifiers 51 (Multiple procedures) and 52 Reduced services can be reported with transluminal angioplasty when appropriate.

The End This concludes the lecture for the Cardiovascular System.

Cardiovascular Systems

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