CARDIOVASCULAR SYSTEM

CARDIOVASCULAR SYSTEM
CHAPTER 17 CARDIOVASCULAR SYSTEM

Cardiovascular System (1 of 2)
CV coding may require codes from: Radiology Medicine Surgery The cardiologist specializes in the treatment of conditions of the heart and may further specialize in the area of radiology, medicine, or surgery. How is coding for the cardiovascular system different from coding for the respiratory system? (Nearly all respiratory system codes are grouped together in one section of the CPT; cardiovascular system codes are found in three separate locations in the CPT: Radiology, Medicine, and Surgery.) What types of codes are included in each of the three sections? (Radiology: diagnostic study or radiologic visualization; Medicine: nonsurgical cardiovascular services; Surgery: cardiovascular surgical procedures)

Cardiovascular System (2 of 2)
Radiology: Diagnostic studies Medicine: Nonsurgical and percutaneous Surgery: Open and percutaneous How does coding for the cardiovascular system mirror the practice of medicine for the cardiology specialty? (Sections correspond to the subspecialties found among cardiologists.) Fig (p. 457) lists the section information that is most often used when cardiovascular services are reported. What are some key factors that can help avoid confusion and clarify cardiovascular coding? (Understanding the components of coding for cardiovascular services, the various locations of the service codes, and the associated terminology)

Cardiology Coding Terminology (1 of 4)
Invasive: Enters body Example: Opening chest for removal, tumor on heart or percutaneous placement of catheter in artery Both Medicine and Surgery sections contain invasive procedures Invasive procedures break the skin and are used to make a correction or to examine the cardiac system. In which section would one code cardiac catheterization? (Medicine) Which section of the CPT will include codes for invasive procedures? (It depends on the nature and extent of the procedure; codes from any of the three sections may be used for invasive procedures.)

Noninvasive: Procedures that do not break skin Example: Electrocardiogram For what purpose are noninvasive procedures most often performed? (Diagnostic purposes) Are noninvasive procedures ever coded to the Surgery section? (No, surgery by definition is an invasive procedure.) Procedures in this category may be coded to the Radiology section or to the Medicine section.

Electrophysiology (EPS): Study of electrical system of heart Example: Study of irregular heartbeat (arrhythmia) What types of electrophysiology procedures would be coded in the Medicine section? (Invasive procedures such as heart catheterization) In which section are more invasive treatments coded? (Surgery) Are codes from this category ever found in the Radiology section of the CPT? (No, radiological guidance is not required for these procedures.) Figure 17.30

Nuclear Cardiology: Diagnostic and treatment specialty, uses radioactive substances for cardiac conditions Example: MRI Codes from which section of the CPT are used for nuclear cardiology? (Primary codes for these procedures come from the Radiology section, where review of diagnostic and treatment information accumulated during the procedure occurs; some components of the procedures may be coded elsewhere to Surgery [e.g., insertion of a catheter] and/or Medicine [e.g., contrast material used in the procedure].)

Cardiovascular in Surgery Section
Codes for procedures: Heart/Pericardium ( ) Pacemakers, valve disorders Arteries/Veins ( ) The Cardiovascular System subsection ( ) of the Surgery section contains diagnostic and therapeutic procedure codes. What is the first step involved in selecting a code for a cardiovascular procedure that will be coded to the Surgery section of the CPT? (Identifying the anatomical location of the procedure) Where would you find codes for a heart valve repair? (The Heart and Pericardium subheading [ ])

Heart/Pericardium (33010-33999) (1 of 2)
Both percutaneous and open procedures Extensive notes throughout Frequent changes with medical advances Codes in this subheading are used for services to repair the heart, pericardium, or coronary vessels. Why is it important to read all of the notes contained in the CPT for a particular section when coding from that section? (Notes contain valuable information that will describe the ways in which codes in a particular area of the CPT can be used; ignoring these notes can result in errors.)

Heart/Pericardium (33010-33999) (2 of 2)
Examples of Heart/Pericardium subheadings: Pericardium Cardiac Tumor Pacemaker or Implantable Defibrillator Why are many revisions and additions made to this subheading each year? (They reflect the many advances in this area.) There are only 2 codes that fall under the Cardiac Tumor category. How are these codes divided out? (Intracardiac—tumor is within the heart muscle, or external—tumor is lying on the outside of the heart muscle.)

Heart/Pericardium Categories
Pericardiocentesis: Percutaneous withdrawal of fluid from pericardial space Excision of Cardiac Tumor: Open surgical procedure for removal of tumor on heart Pericardiocentesis is the most commonly performed procedure of the pericardium. How is pericardiocentesis coded if the insertion to withdraw fluid is performed with radiologic guidance? (The radiologic guidance would be coded separately with use of a code from the Radiology section.) Are the same codes used for excision of pericardial and cardiac tumors? (No, separate codes are provided for these two procedures.)

Pacemaker or Implantable Defibrillator (33202-33273) (1 of 6)
Devices that assist heart in electrical function How does a pacemaker work? (Device wires are threaded through the superior vena cava and into the heart itself, enabling the device to shock the heart into a regular rhythm.) What are the main parts of a pacemaker? (Pulse generator [battery] and electrodes [leads]) Does a pulse generator (battery) ever need to be replaced? (Yes, just like normal batteries for a flashlight or watch, these too need to be replaced.) Figure 17.7 A, Single pacemaker insertion. B, Dual chamber pacemaker. C, Biventricular pacemaker. (B from Lewis SL, Bucher L, Heitkemper MM, Harding MM: Medical-Surgical Nursing: Assessment and Management of Clinical Problems, ed 10, St. Louis, 2017, Elsevier.)

Figure 17.5 Divided by where electrodes (leads) placed, approach, and type of service Pacemaker electrically stimulates myocardium of one or more chambers to contract when heart fails to do so Device can be temporary or permanent What must be known for a pacemaker to be coded correctly? (The approach, epicardial or transvenous. Whether the procedure involves initial placement, replacement, or repair and of what components for the procedure. Where the electrodes are being placed.) From Forbes CD, Jackson WF: Color Atlas and Text of Clinical Medicine, ed 3, 2003, Mosby.

Figure 17.6 Placed: Atrium, single chamber (uses 1 lead) Ventricle, single chamber Both, dual chamber (uses 2 leads) Biventricular, both ventricles and right atrium (3 leads) Where can the electrode(s) (lead) for a pacemaker be placed? (Atrium [single], ventricle [single], or both [dual]) There is also a pacemaker that has 3 leads called a biventricular pacemaker that has a lead in the atrium, right ventricle, and left ventricle. This is used in treatment of congestive heart failure. From Miller RD, editor: Miller's Anesthesia, ed 7, Philadelphia, 2010, Churchill Livingstone.

Approach: Epicardial: Open procedure to place on heart Transvenous: Through vein to place in heart How are codes for the epicardial approach further divided? (According to the approach, open incision or endoscopic, to the chest wall that is used) How are codes for the transvenous approach further divided? (According to the area of the heart into which the pacemaker is inserted) How is the fluoroscopic portion of the transvenous procedure coded? (With the use of a radiology code)

Type of Service Initial placement or replacement of all or part Number of leads placed Type of service is also important when pacemaker and implantable defibrillator procedures are coded. How are the pacemaker/implantable defibrillator codes subdivided? (They are subdivided on the basis of location of the implant, approach used to place the device, and the type of service provided in conjunction with placement of the device.)

Patient record indicates revision or replacement Usual follow-up period 90 days (global period) Use -78 to indicate return to operating room within global period When would the modifier -24 be used in association with a pacemaker or an implantable defibrillator? (For an evaluation and management level, if patient is seen in the postoperative [global] period for a reason that is not pertaining to the surgery) When would the modifier -78 be used in association with a pacemaker or implantable defibrillator? (If the patient is returned to the operating room for repositioning or replacement of the device within the global period) What would happen if the modifiers -78 and -24 were not used? (Separate deliverables would not be paid because the third-party payer would treat them as services included for the global period.)

Electrophysiologic Operative Procedures (33250-33266) (1 of 2)
Surgeon repairs defect causing abnormal rhythm Endoscopy Procedure Without CP Codes based on reason for procedure, approach, and if CP bypass used Why are electrophysiologic operative procedures performed? (To repair a defect in the heart that interferes with normal electrical activity) How are codes divided for electrophysiologic operative procedures? (Electrophysiologic operative procedures are divided by the approach—incision or endoscopy—if cardiopulmonary bypass was used, and the extent of the procedure.)

Electrophysiologic Operative Procedures (33250-33266) (2 of 2)
Chest opened to full view—Incision Cardiopulmonary (CP) bypass usually used Codes are further divided if the procedure was limited or extensive and with or without cardiopulmonary bypass. What is the definition of limited? (The surgical isolation of triggers of SV dysrhythmias by operative ablation that isolates pulmonary veins or other triggers in the left or right atrium) Who would determine the extent of the procedure? (The physician performing the procedure)

Patient-Activated Event Recorder (33285, 33286)
Also known as cardiac event recorder or loop recorder Placed using a small parasternal incision Divided based on device being inserted or removed Why is a patient-activated event recorder used? (To help diagnose hard-to-detect rhythm problems) The patient pushes a button to activate the device according to instructions provided by the physician. Is the placement of a patient-activated event recorder an invasive or a noninvasive procedure? Why? (It is an invasive procedure because the leads for the device are placed inside the body.)

Cardiac Valves (33361-33478) Divided on valve and CP bypass:
Aortic, mitral, tricuspid, pulmonary Transcatheter Aortic Valve Replacement (TAVR)/Implant (TAVI) Via artery: Percutaneous, open, or transaortic Codes divided based on the approach add-on codes reported in addition to more primary procedure Where are cardiac valve procedures located in the CPT manual? (In the Surgery section, the Cardiovascular subsection, the Heart and Pericardium subheading, and the Cardiac Valves category) The procedures used to replace cardiac valves are similar for all types of valves, and descriptions for the codes used with these procedures are similar as well. What is a cardiopulmonary bypass machine? (It assumes the patient’s heart and lung function during surgery.)

Coronary Artery Bypass Graft
CABG performed for coronary arteries severely clogged (atherosclerosis) Fig. 17.8A shows various levels of coronary artery occlusion caused by the build-up of plaque. What are the possible results of arteriosclerotic coronary artery disease? (The patient could have a myocardial infarction that could lead to cardiac arrest and death.) Figure 17.8A

Coronary Artery Bypass (1 of 2)
Figure 17.9 Determine what was used in repair: Vein ( ) Artery ( ) Both artery and vein ( and ) What distinguishes reversible from irreversible ischemia? (In the case of reversible, if blood flow is increased to the heart muscle, it may begin to function at normal or near-normal levels rather than suffer the irreversible death of heart muscle.) What is the goal of a coronary artery bypass? (To bypass the diseased vessel to bring good blood flow to the heart.) What is a percutaneous transluminal coronary angioplasty? (A balloon is expanded in the artery to push a blockage to the sides of the coronary arterial walls.)

Coronary Artery Bypass (2 of 2)
Number of bypass grafts performed and if vein and arterial grafts are used Example: Three venous grafts What may lead to the need to perform more than one graft? (If more than one vessel or more than one area of a vessel is severely diseased) There are times when a patient may need a repeat bypass and code would be used to show the third-party payer that this is a reoperation. A reoperation makes this a more labor-intensive surgical procedure due to things like scarring from previous bypass.

Venous Grafting Only for Coronary Artery Bypass Graft
Codes Divided based on number of grafts being placed Procurement of saphenous vein included in procedure (not coded separately) when retrieved through open incision Code reported separately Endoscopic, surgical, video-assisted harvest of vein(s) Add-on code, do not append -51 Why is it inappropriate to use the multiple procedures modifier -51 when coding the harvest of a vein for graft through endoscopic, surgical, or video-assisted harvesting techniques? (The code used for the harvesting, 33508, is an add-on code that may be used only in conjunction with one of the codes from the bypass section, codes ; no modifier is necessary because it is expected that this will be used with the code for the bypass procedure.)

Arterial Grafting (33533-33548) (1 of 2)
Divided based on number of grafts Right coronary artery (RCA) has two branches Right marginal Right posterior descending (PDA) Left main coronary artery (LMCA) has seven branches 1) Left anterior descending, 2) diagonal, 3) septal, 4) circumflex (LCX), 5) obtuse marginal (OM), 6) posterior descending, 7) posterolateral What procedures are codes used for? (These codes are used for coronary bypass surgery performed with the use of arterial grafts.) Codes are procedures performed on arteries during the bypass procedure.

Arterial Grafting (33533-33548) (2 of 2)
Several codes ( ) for myocardial resection, repair of a ventricular septal defect, and ventricular restoration procedures Obtaining artery for grafting included in codes, except: Procuring an upper extremity artery (i.e., radial artery), coded separately (35600) How is harvesting of an artery used as a graft in a coronary bypass procedure coded? (It is included in the code for the bypass procedure except in those cases where an upper extremity artery [i.e., a radial artery] is used; in that case, it is coded separately as )

Combined Arterial-Venous Grafting (1 of 2)
Codes Divided based on number of grafts Report combined arterial-venous procedures with two codes: 1) appropriate combined arterial-venous graft code, and 2) appropriate arterial graft code ( ) The -51 modifier not used with these codes When are the codes under the Arterial-Venous category used? (These codes are used for coronary artery bypass surgery in which both arterial and venous grafting is done. They represent the vein portion of the combined artery–vein bypass.) The codes from range are never to be used alone. They are to be only used in conjunction with They are also modifier -51 exempt.

Combined Arterial-Venous Grafting (2 of 2)
Procuring saphenous vein included, if open retrieval Endoscopic harvest is reported with 33508 If reoperation report with 33530 No modifier -51, add-on codes Never used alone Add-on codes always used with Arterial Grafting codes ( ) Arterial-Venous codes report only venous graft portion of procedure Open procurement of the saphenous vein for grafting is bundled into the bypass procedure and is not billed separately. If the vein were procured through the endoscope for video-assisted harvesting, this would be separately reported with the code Procurement of an upper extremity vein would be separately reported with the code When might a physician not want to use a vein from a patient’s leg and choose an upper extremity vein instead? (Patient has PVD or diabetes)

Endovascular Repair of Descending Thoracic Aorta (33880-33891)
Placement prostheses for repair of descending thoracic aorta Synthetic aortic prostheses placed via catheter Less invasive than chest or abdominal incision Report fluoroscopic guidance separately, Includes diagnostic imaging (pre- and intraoperative) Stent-graft (endoprosthesis) reinforces weakened area These codes are used to report placement of endovascular placement of grafts for repairs of the descending thoracic aorta. These codes include device introduction, manipulation, positioning, and deployment. If an angioplasty or stenting is used to aid in the repair, these are bundled services and not reported separately.

Extracorporeal Membrane Oxygenation and Extracorporeal Life Support Services (33946-33989)
Cardiac and/or respiratory support to the heart and/or lungs These systems provide cardiac and respiratory support for patients whose heart and lungs are diseased or damaged beyond function These codes are used to report placement of endovascular placement of grafts for repairs of the descending thoracic aorta. These codes include device introduction, manipulation, positioning, and deployment. If an angioplasty or stenting is used to aid in the repair, these are bundled services and not reported separately.

Arteries and Veins (34001-37799) (1 of 3)
Only for noncoronary vessels Divided based on whether artery or vein used Example: Different codes for embolectomy, depending on artery or vein Codes describe excision of acquired thrombus or congenital thrombus of an artery or vein Thrombus, aggregation of blood factors frequently causing vascular obstruction at the point of formation Where are procedures involving coronary arteries or veins coded? (Under the Heart/Pericardium subheading, not under the Arteries and Veins subheading) This subheading contains codes for all other vessels of the body other than those of the heart (noncoronary).

Figure 17.14 Catheters placed into vessels for monitoring, removal, repair Using nonselective or selective catheter placement From Roberts JR, Hedges JR, editors: Clinical Procedures in Emergency Medicine, ed 4, Philadelphia, 2004, Saunders. Catheterization is a main procedure coded within this subheading. On what is coding of catheter placement based? (Where the catheter starts and where it ends)

Nonselective: Direct placement without further manipulation Selective: Place and then manipulate into further order(s) Codes are divided by selective or nonselective placement. Understanding these definitions is very important.

Catheter Placement Example
Nonselective: 36000, Introduction of needle into vein Selective: 36012, Placement of catheter into second order venous system How are these two procedures different? (Code describes the placement of a needle or catheter into a vein without further movement, which is a nonselective procedure; code describes the placement of a catheter into a vein with further manipulation to a second-order vein.)

Vascular Families Are Like a Tree
Main branch—first order (tree trunk) Second order branch (tree limb) Third order branch (tree branch) Appendix L, CPT, Vascular Families Lists first, second, third, and beyond third order branches Assumption that starting point is catheterization of aorta What is a “vascular family” and how does it relate to nonselective and selective catheter placement? (A vascular family includes a main vessel and its branches; selective placement manipulates the catheter into a branch.) The first order is the main artery or vascular family; the second order is the branch off the main artery; the third order branches off the second order and so on. Can a vascular family have more than one first-order branch? (No) Appendix L of CPT is a great tool for showing vascular families.

Innominate/Brachiocephalic Vascular Family
Report farthest extent of catheter placement in a vascular family A vascular family will have only one first-order artery but may have multiple second-order arteries, third-order arteries, etc. If the catheter placement continued from one second-order branch of the brachiocephalic artery into another second-order branch of the artery, you would report the additional second order, third order, and beyond with the use of an add-on code— All subsequent catheter placements should be reported to the fullest extent of those placements. Figure 17.15

Embolectomy and Thrombectomy (34001-34490)
Embolus: Dislodged thrombus Thrombus: Mass of material in vessel, in place of formation Balloon removal: Threaded into vessel, inflated under mass, pulled out with mass What is an embolectomy? (Removes an embolus, a blood clot, or other mass of undissolved matter present in and transported by the blood) What is a thrombectomy? (Removes a thrombus or blood clot that occludes a vessel) Why wouldn’t separate codes be needed to distinguish between embolectomy or thrombectomy? (The procedures followed to clear clots or debris from the vessels are the same.)

Embolectomy Removal of embolus Figure 17.16
What procedure is shown in Fig ? (The use of a catheter to remove an embolus from a vessel in the leg) Figure 17.16

Venous Reconstruction (34501-34530)
Types of repair: Valve of femoral vein Vena cava Saphenopopliteal vein anastomosis How are valve repairs performed? (Vessels that lead to the valve are clamped so that excessive material surrounding the valve may be tacked down with the use of sutures [plication]; grafts, harvested elsewhere, may be required in some cases.) What is involved in vein repair? (Locating the defective vessel, clamping the vessel off, and bypassing or grafting the defect) Aneurysms, sacs of clotted blood, are repaired by clamping above and below the aneurysm and then removing or bypassing it. Are these procedures invasive or noninvasive? (These are invasive surgical procedures.)

Aneurysm (1 of 2) Aneurysm: ballooned or weakened area of vessel
To select the correct code, check the operative report for: Type of prosthesis Location of aneurysm Any additional services to facilitate placement of endograft Whether open artery access was performed, and if so, was conduit created Whether open repair was required Why is an aneurysm dangerous? (If the area deteriorates without repair, excessive bleeding will occur at the site, causing injury or death.) How are aneurysm repair codes divided? (By type of aneurysm and the vessel that it is located in)

Aneurysm (2 of 2) Repair by removal, bypass, or coil placement
Coil placement: Tiny, flexible, platinum coil pushed into aneurysm and forms “ball” to obstruct blood flow into aneurysm Endovascular repair ( ) from inside vessel Direct ( ) from outside vessel Aneurysm repair is coded according to the type of aneurysm (e.g., false, ruptured) and the location of the aneurysm (e.g., subclavian artery, popliteal artery). What other factor(s) determine the coding of aneurysm repair? (Aneurysms are also coded according to approach, which may be endovascular [from inside the vessel] or direct [from outside the vessel].)

Endovascular Repair of Abdominal Aortic Aneurysm
Extensive notes preceding codes—“must reading” Includes access, catheter manipulation, balloon angioplasty, stent placement, site closure Other procedures performed at same time are coded separately Verify bundled codes in CCI edits Which groups are most susceptible to abdominal aortic aneurysms? (The elderly, particularly males) Why is it important to read the notes preceding this section of the CPT? (It is always important to read the notes included in the CPT, regardless of the section in which they appear; notes provide information that is essential for accurate coding.)

Endovascular Repair of Iliac Aneurysm (34707-34708)
Extensive notes before codes Includes positioning, deployment of stent or balloon angioplasty Report separately Open femoral or iliac artery exposure Introduction of guidewires or catheters Extensive artery repair or replacement How should the individual procedures associated with endovascular repair be coded? (Individual procedures should not be coded separately; however, other procedures performed at the same time should be coded separately with use of the appropriate CPT modifier code for multiple procedures.) Which CPT modifier is used to indicate that multiple procedures have been performed? (CPT modifier -51)

Repair Arteriovenous Fistula (35180-35190)
Abnormal passage Divided based on fistula type: Congenital Acquired/traumatic By site What is an arteriovenous fistula? (An abnormal passage that allows blood to flow between an artery and a vein) Repair of the fistula involves separating the artery from the vein and patching the area of separation with sutures or a graft. Are codes for this procedure divided by approach? (No)

Angioplasty Open or percutaneous by vessel
Transluminal angioplasty: Catheter passed into vessel and stretched Code per vessel Stent placement reported separately Code imaging separately Reported with codes 36902, 36905, 36907, and What are the purposes of angioplasty and atherectomy procedures? (To treat atherosclerotic disease) Which of these would be an invasive procedure? (Both are invasive because both involve entering the body; the open procedure is, however, more invasive than the percutaneous method.)

Noncoronary Bypass Grafts (35500-35671)
Divided by: Vein In-Situ Veins (veins repaired in their original place) Other than Vein Coded according to the beginning and ending vessels of the graft and vein used for the graft How are noncoronary bypass grafts coded? (According to the source of the material used in the graft and the specific vessels affected by the graft.)

Bypass Graft, Vein Code by type of graft and vessels being used to bypass Example: 35506, Bypass graft, with vein; carotid-subclavian or subclavian-carotid Graft attached to carotid and to subclavian, bypassing a defect of subclavian What type of material can be used for the graft? (A venous graft that is attached to the carotid and subclavian arteries) How can graft codes for this procedure be located in the CPT manual? (One way is to look under “Bypass Graft” in the Index and then under subterm type.)

Vascular Injection Procedures (36000-36522) (1 of 2)
Divided into: Intravenous Intra-Arterial—Intra-Aortic Venous Injection codes bundle together all services required to complete the procedure, including use of local anesthesia, introduction of needle or catheter, injection of contrast media, and pre-injection and post-injection care related to the procedure. How are the catheter, drugs, and contrast media used in this procedure coded? (Not included in the bundle and must be coded separately.) Which section of the CPT includes the codes used for materials and supplies required to support a procedure (including this one)? (The Medicine section)

Vascular Injection Procedures (36000-36522) (2 of 2)
Used for many procedures, includes: Local anesthesia Introduction of needle Catheter Injection of contrast material Pre- and postoperative care Example: Injection of an opaque substance for venography What is venography? (An imaging procedure involving the veins) Injection of opaque substances will improve the detail of the images created with this procedure.

Transcatheter Procedures (37184-37218)
Arterial mechanical thrombectomy ( ) Removal of arterial thrombus by mechanical device Used to report a variety of transcatheter procedures Venous mechanical thrombectomy (37187, 37188) Removal of venous thrombus by means of a mechanical device Mechanical thrombectomy is divided by whether it is venous or arterial. They are further divided by primary vessel and second and all subsequent vessels. These are performed on noncoronary vessels.

Cardiovascular in Medicine Section (1 of 2)
Services can be: Invasive or noninvasive Diagnostic or therapeutic How does an invasive procedure in the Cardiovascular subsection from the Medicine section differ from one in the Surgery section? (Invasive treatments are not a matter of cutting open the body so the surgeon can view it; they are invasive in that an incision or puncture is made into the skin.)

Cardiovascular in Medicine Section (2 of 2)
Subheadings: Coronary Therapeutic Services and Procedures Cardiography Cardiovascular Monitoring Services Implantable, Insertable, and Wearable Cardiac Device Evaluations Echocardiography What commonly used cardiovascular codes are included in the Therapeutic Services subheading? (Cardioversion, infusion, thrombolysis, placement of catheters and stents, atherectomy, and angioplasty)

CV in Medicine Section Cardiac Catheterization
Intracardiac Electrophysiologic (EP) Procedures/Studies Peripheral Arterial Disease (PAD) Rehabilitation Noninvasive Physiologic Studies and Procedures Other Procedures Are any of the subheadings in this slide coded as invasive procedures? (Cardiac catheterization, Intracardiac EP procedures/studies) What is included in Other Vascular Studies? (Plethysmography, electronic analysis, thermograms, and ambulatory blood pressure monitoring)

Therapeutic Services and Procedures (92920-92998) (1 of 2)
Types of services: Cardioversion Infusions Thrombolysis Catheter placement Many of these services used to be performed with the use of open procedures, but they are now performed percutaneously.

Therapeutic Services and Procedures (92920-92998) (2 of 2)
Many groups of codes are divided by: Method (e.g., balloon, blade) Location (e.g., aortic or mitral valve) Number (e.g., single or additional vessels) What are some of the procedures that are included in Therapeutic Services? (Thrombolysis, endoluminal imaging, intracoronary stent placement, and valvuloplasty)

Cardiography and Cardiovascular Monitoring Services (93000-93278) (1 of 2)
Types of service: Stress tests Holter monitor Figure 17.22 Figure 17.24 What is the purpose of a stress test? (To test the adequacy of the amount of oxygen getting to the heart muscle) From Young AP, Proctor DB: Kinn's The Medical Assistant, ed 10, St. Louis, 2007, Saunders. From Forbes CD, Jackson WF: Color Atlas and Text of Clinical Medicine, ed 3, 2003, Mosby.

Cardiography and Cardiovascular Monitoring Services (93000-93278) (2 of 2)
Electrocardiogram Separate codes for global procedure and components (professional and technical) See 93000, 93005, 93010 The electrocardiogram (ECG) provides a reading of the electrical currents of the heart and is a standard test conducted to detect suspected cardiac abnormalities. How do you determine which of the ECG codes should be used? (If the same physician performs, interprets, and reports on the results of the ECG, code should be used; if one physician performs the ECG and another interprets and reports on the results, codes and should be used for these procedures.)

Holter Report Used to identify cardiac arrhythmias Figure 17.26
Fig illustrates a Holter report. The report summarizes cardiac activity over the 24-hour period during which the patient wears the monitor. The report is produced via computer analysis of cardiac output during the time when the patient wears the Holter device. When is the Holter procedure preferred over an ECG? (When diagnosis is difficult because cardiac irregularities are sporadic rather than continuous) Figure 17.26

Implantable, Insertable, and Wearable Cardiac Device Evaluations (93264, 93279-93299)
Category notes include definitions and instructions Extensive notes

Echocardiography ( ) Figure 17.27 What is the purpose of the echocardiography procedure? (Ultrasound images are used on the heart to detect the presence of heart or valvular disease.) Which part of the procedure would be classified as technical? (Creating the image) Which part would be classified as professional? (Interpreting the image and reporting on it) Noninvasive diagnostic procedure: Ultrasound detects presence of cardiac or vascular disease

Cardiac Catheterization (93451-93572) (1 of 2)
Used to identify valve disorders, abnormal blood flow Many bundled services in catheterization codes Cardiac catheterization is a diagnostic medical procedure. The procedure may be performed percutaneously. Is cardiac catheterization an invasive procedure? (Yes, all percutaneous procedures are invasive because they require entry into the body.)

Cardiac Catheterization (93451-93572) (2 of 2)
Example: Introduction Positioning/repositioning of catheter Pressure readings inside heart or vessels Blood samples Rest/exercise studies Final evaluation and report Many codes modifier -51 exempt

Three Components of Coding Cardiac Catheterization
Placement of catheter Injection Imaging supervision, interpretation, and report All 3 components are included in most catheterization codes Some cardiac catheterization codes require an imaging/injection code , catheterizations for congenital anomalies require or (imaging/injection) Besides these three components of placement, injection and imaging, what other service is included in cardiac catheterization codes? (Image supervision and interpretation) From LaFleur Brooks M: Exploring Medical Language: A Student-Directed Approach, ed 7, St. Louis, 2009, Mosby.

Intracoronary Brachytherapy (92974) (1 of 2)
New procedure uses radioactive substances to destroy restenosis of coronary vessel Patients have had stent placed in coronary vessel Stent “restenosis” (reformation of plaque) From Zipes DP, editor: Braunwald's Heart Disease, ed 7, Philadelphia, 2005, Saunders A stent may be placed in a coronary artery to open a vessel blocked with plaque (i.e., stenosis). Intracoronary brachytherapy is used to reopen the vessel. The radioactive strip is left in place for up to 45 minutes before it is removed. Figure 17.29 Brachytherapy delivery system for coronary artery stent restenosis From Zipes DP, editor: Braunwald's Heart Disease, ed 7, Philadelphia, 2005, Saunders

Intracoronary Brachytherapy (92974) (2 of 2)
Cardiologist: Places guidewire and catheter Radiation oncologist: Places radioactive elements How would the two components of this procedure be coded? (Separately because they are performed by different specialists)

Intracardiac Electrophysiologic Procedures/Studies (93600-93662)
Services to diagnose and treat conditions of electrical system of heart Tests involve placement of special catheters into heart and cardiac vessels for purpose of pacing and recording intracardiac activity Intracardiac electrophysiologic procedures/studies are less invasive than those coded in the Surgery section for repair of the electrical system of the heart. Which procedures from the Surgery section describe electrophysiologic procedures/studies are commonly used to treat conditions of the electrical system of the heart? (Insertion of a pacemaker or implantable defibrillator would be coded in this section.)

EP System of Heart (1 of 3) Electrical conduction system Figure 17.30
How do impulses pass through the electrical conduction system of the heart? (Conduction begins with the sinoatrial node [SA], known as the heart’s pacemaker. The sinoatrial node sends impulses to the atrioventricular [AV] node, which in turn passes the impulses to the bundle of His, and finally on to the Purkinje fibers to stimulate the ventricles of the heart.) Lesions or diseases involving these structures along the electrical conduction pathway underlie many disturbances of cardiac rhythm. Figure 17.30

EP System of Heart (2 of 3) Electrical recording codes divided based on location of recording device Example: Bundle of His or right ventricle How are electrophysiologic abnormalities diagnosed? (By recordings taken at various sites along the pathway) Arrhythmia may also be induced as part of this procedure. Codes for this service are bundled and may include several procedures. Parenthetical notes at the end of code descriptions describe the services included in each bundle and the situations in which the codes should be used. What will happen if parenthetical notes are ignored? (Coding errors will result.)

EP System of Heart (3 of 3) Pacing: Temporary pacing to stabilize beating of heart Example: Intraventricular or intra-arterial pacing Pacing is a procedure that temporarily stabilizes heart rhythm through the use of electrophysiologic procedures. How is pacing coded? (According to location as intraventricular or intra-arterial)

Peripheral Arterial Disease (PAD) Rehabilitation (93668)
Rehabilitation sessions: minutes Use of motorized treadmill/track to build patient’s CV endurance Supervised by exercise physiologist or nurse Peripheral arterial disease rehabilitation consists of physical exercises designed to enhance a patient’s cardiovascular endurance. Symptoms of cardiac distress are recorded for review by the patient’s physician. Why is it important that the patient be supervised during these exercise sessions? (Supervision allows for the collection of data regarding any cardiac symptoms that occur during exercise and ensures that the session is terminated, if appropriate.)

Noninvasive Physiologic Studies and Procedures (93701-93790) (1 of 3)
Category contains codes for services such as: Plethysmography: Recordings of changes in size of body part when blood passes through it Patients who have had pacemakers or defibrillators inserted require periodic monitoring to ensure that these devices are functioning properly. These services are coded from the Noninvasive Physiologic Studies and Procedures category. How are codes divided for these procedures? (If it is a pacemaker or defibrillator, if it is a dual or single device, and whether reprogramming is required)

Electronic Analysis: Checks electronic function of devices, such as pacemakers Electronic analysis must be performed periodically to verify the functioning of devices such as a pacemaker and implantable defibrillator once they have been implanted. An electrocardiogram and other analyses of the device are performed. Are separate codes provided for analysis of single- and dual-chamber pacemakers? (Yes)

Ambulatory Blood Pressure Monitoring: Outpatient basis over 24-hour period Thermograms: Visual recordings of temperature of body What is the purpose of these procedures? (To evaluate the general functioning of the cardiovascular system) What is involved in ambulatory blood pressure monitoring? (Recording, analysis, and interpretation/report) Coding may be done for the total procedure or for each of its components. What might varying temperatures in different parts of the body indicate? (Areas of vascular insufficiency) From Forbes CD, Jackson WF: Color Atlas and Text of Clinical Medicine, ed 3, 2003, Mosby.

Cardiovascular in Radiology Section (1 of 4)
Divided complete procedures into two components: Technical and Professional Why is it useful to have separate codes for the technical and professional components of these codes? (These allow for the flexibility to address situations in which both components are provided by the same physician and situations in which different physicians provide each component.)

Radiology Section, Heart ( ), and Aorta/Arteries ( ) subsections Codes in the Heart subsection are used to report cardiac magnetic resonance imaging (MRI). Codes from the Aorta/Arteries subsection document aortography, excluding the heart. What do the statements “supervision and interpretation” refer to in this service? (The professional components of the service)

Example: Angiography Technical component angiography—remains in Radiology Section Professional component injection—moved to Surgery Section What is the purpose of the modifiers -26 and -TC when used here? (To clarify the portions of the service delivered by the physician and the facility)

Complete angiography requires radiology code and surgery code Reflects common practice of cardiologist performing injection and radiologist reporting angiography results In most situations in which angiography is done, a cardiologist performs the injection and a radiologist performs the angiography itself. If a cardiologist performs both the technical and the professional components of this procedure, how will it be coded? (Both components will be coded by the physician who is delivering it, without either modifier -26 or -TC. No modifier would be used with the CPT code to show global billing.)

Contrast Material (1 of 2)
Often radiologic procedures use contrast material to improve image Many codes have contrast material bundled into service “With contrast” or “with or without contrast” Only injected contrast qualifies When contrast material is used with a radiologic procedure, it may be bundled into the procedure code. If contrast material is not bundled, how is it coded? (From the Medicine section of the CPT, so long as the material is injected) How can you determine if the use of injected contrast is bundled into the procedure code? (Read the code description, any notes appended to the section in which the code is found, and any parenthetical notes appended to the code.)

Contrast Material (2 of 2)
Contrast not included in description, used in procedure; code both contrast material and injection separately Physician performs injection procedure in hospital outpatient department; use modifier -26 for professional component only How is the contrast material injected? (The code description for the major procedure may include this procedure. Reading the code description will indicate whether that is the case. If it is not included, it should be coded separately. In addition, if a physician performs the procedure in a hospital outpatient department, modifier -26 should be appended to the professional component only.)

A Component Coding Example (1 of 2)
Two physicians (cardiologist and radiologist from same facility) perform angiography of third order brachiocephalic artery with contrast Cardiologist placing catheter (36217)— Surgery Section How would the professional component be coded in the example on the slide? (The cardiologist would code placement of the catheter using from the Surgery section.)

A Component Coding Example (2 of 2)
Radiologist performs angiography (Supervision and interpretation) (75710), Radiology Section Supply of contrast material (99070), Medicine Section What additional coding would be appropriate for this procedure? (The radiologist should code the angiography using from the Radiology section; the supply of contrast material should be coded with the use of 99070, taken from the Medicine section.)

CARDIOVASCULAR SYSTEM
Conclusion CHAPTER 17 CARDIOVASCULAR SYSTEM

CARDIOVASCULAR SYSTEM

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