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CHAPTER 21

CHAPTER 21. CARDIOVASCULAR SYSTEM. Cardiovascular System. CV coding may require codes from: Radiology Medicine Surgery (Cont’d…). Cardiovascular System. (…Cont’d) Radiology: Diagnostic studies Medicine: Nonsurgical and percutaneous Surgery: Open and percutaneous.

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CHAPTER 21

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  1. CHAPTER 21 CARDIOVASCULAR SYSTEM

  2. Cardiovascular System • CV coding may require codes from: • Radiology • Medicine • Surgery (Cont’d…)

  3. Cardiovascular System (…Cont’d) • Radiology: Diagnosticstudies • Medicine: Nonsurgical and percutaneous • Surgery: Open and percutaneous

  4. Cardiology Coding Terminology • 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 (Cont’d…)

  5. Cardiology Coding Terminology (…Cont’d) • Noninvasive: Procedures that do not break skin • Example: Electrocardiogram (Cont’d…)

  6. Cardiology Coding Terminology • (…Cont’d) • Electrophysiology (EPS): Study of electrical system of heart • Example: Study of irregular heartbeat (arrhythmia) • (Cont’d…)

  7. Cardiology Coding Terminology • (…Cont’d) • Nuclear Cardiology: Diagnostic and treatment specialty, uses radioactive substances for cardiac conditions • Example: MRI

  8. Cardiovascular in Surgery Section • Codes for procedures: • Heart/Pericardium (33010-33999) • Pacemakers, valve disorders • Arteries/Veins (34001-37799)

  9. Heart/Pericardium (33010-33999) • Both percutaneous and open procedures • Extensive notes throughout • Frequent changes with medical advances (Cont’d…)

  10. Heart/Pericardium (33010-33999) (…Cont’d) • Examples of Heart/Pericardium subheadings: • Pericardium • Cardiac Tumor • Pacemaker orCardioverter-Defibrillator

  11. Heart/Pericardium Categories • Pericardiocentesis: Percutaneous withdrawal of fluid from pericardial space • Excision of Cardiac Tumor: Open surgical procedure for removal of tumor on heart

  12. Pacemaker or Pacing Cardioverter-Defibrillator (33202-33249) • Devices that assist heart in electrical function Figure: 21.7A, Single pacemaker. B, Dual chamber pacemaker. C, Biventricular pacemaker. (B from Christensen BL, Kockrow ED: Adult Health Nursing, ed 5, St. Louis, 2006, Mosby.) (Cont’d…)

  13. Pacemaker or Pacing Cardioverter-Defibrillator (33202-33249) Figure: 21.5 (…Cont’d) • Divided by where electrodes 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 (Cont’d…) From Forbes CD, Jackson WF: Color Atlas and Text of Clinical Medicine, ed 3, 2003, Mosby.

  14. Pacemaker or Pacing Cardioverter-Defibrillator (33202-33249) Figure: 21.6 (…Cont’d) • Placed: • Atrium (single chamber) • Ventricle (single chamber) • Both (dual chamber) • Biventricular, both ventricles and right atrium (uses 3leads) (Cont’d…) From Miller RD, editor: Miller's Anesthesia, ed 6, Philadelphia, 2005, Churchill Livingstone.

  15. Pacemaker or Pacing Cardioverter-Defibrillator (33202-33249) (…Cont’d) • Approach: • Epicardial: Open procedure to place on heart • Transvenous: Through vein to place in heart (Cont’d…)

  16. Pacemaker or Pacing Cardioverter-Defibrillator (33202-33249) (…Cont’d) • Type of Service • Initial placement or replacement of all or part • Number of leads placed (Cont’d…)

  17. Pacemaker or Pacing Cardioverter-Defibrillator (33202-33249) (…Cont’d) • 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

  18. Electrophysiologic Operative Procedures (33250-33266) • Surgeon repairs defect causing abnormal rhythm • Endoscopy Procedure • Without CP • Codes based on reason for procedure, approach, and if CP bypass used

  19. Electrophysiologic Operative Procedures (33250-33266) • Chest opened to full view—Incision • Cardiopulmonary (CP) bypass usually used

  20. Patient-Activated Event Recorder (33282, 33284) • Also known as cardiac event recorder or loop recorder • Internal surgical implantation required • Divided based on device being implanted or removed

  21. Cardiac Valves (33400-33496) • Divided on valve and CP bypass: • Aortic • Mitral • Tricuspid • Pulmonary • Code descriptions all similar

  22. Coronary Artery Bypass Graft • CABG performed for coronary arteries severely clogged (atherosclerosis) (Cont’d…) Figure: 21.8A

  23. Coronary Artery Bypass Figure: 21.9 (…Cont’d) • Determine what was used in repair: • Vein (33510-33516) • Artery (33533-33536) • Both artery and vein (33517-33523 and 33533-33536) (Cont’d…) From Chabner DE: The Language of Medicine, ed 8, St. Louis, 2007, Saunders.

  24. Coronary Artery Bypass (…Cont’d) • Number of bypass grafts performed and if vein and arterial grafts are used • Example: Three venous grafts

  25. Venous Grafting Only for Coronary Artery Bypass Graft • Codes 33510-33516 • Divided based on number of grafts being placed • Procurement of saphenous vein included in procedure (not coded separately) when retrieved through open incision • Code + 33508 reported separately • Endoscopic, surgical, video-assisted harvest of vein(s) • Add-on code, do not append -51

  26. Arterial Grafting (33533-33536) • 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) posteriolateral (Cont’d…)

  27. Arterial Grafting (…Cont’d) • Several codes (33542-33548) 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)

  28. Combined Arterial-Venous Grafting • Codes 33517-33523 • 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 (33533-33536). • The -51 modifier not used with these codes (Cont’d…)

  29. Combined Arterial-Venous Grafting (…Cont’d) • Procuring saphenous vein included, if open retrieval • Endoscopic harvest is reported with 33508 • If reoperation report with 33530 • No -51, add-on codes • Never used alone • Add-on codes always used with Arterial Grafting codes (33533-33536) • Arterial-Venous codes report only venousgraft portion of procedure

  30. 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, 75956-75959 • Includes diagnostic imaging (pre- and intraoperative) • Stent-graft (endoprosthesis) reinforces weakened area

  31. Arteries and Veins Subheading (34001-37799) • Only for noncoronaryvessels • 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 (Cont’d…)

  32. Arteries and Veins (34001-37799) Figure: 21.14 (…Cont’d) • Catheters placed into vessels for monitoring, removal, repair • Using nonselective or selective catheter placement (Cont’d…) From Roberts JR, Hedges JR, editors: Clinical Procedures in Emergency Medicine, ed 4, Philadelphia, 2004, Saunders.

  33. Arteries and Veins (34001-37799) (…Cont’d) • Nonselective: Direct placement without further manipulation • Selective: Place and then manipulate into further order(s)

  34. Catheter Placement Example • Nonselective: 36000, Introduction of needle into vein • Selective: 36012, Placement of catheter into second order venous system

  35. 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

  36. Brachiocephalic Vascular Family • Reportfarthestextent of catheter placement in a vascular family Figure: 21.15

  37. 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

  38. Embolectomy • Removal of embolus Figure: 21.16

  39. Venous Reconstruction (34501-34530) • Types of repair: • Valve of femoral vein • Vena cava • Saphenopopliteal vein anastomosis

  40. Aneurysm • 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 (Cont’d…)

  41. Aneurysm (…Cont’d) • 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 (34800-34900) from inside vessel • Direct (35001-35152) from outside vessel

  42. Endovascular Repair of Abdominal Aortic Aneurysm • 34800-34834 • Extensive notes preceding codes—“must reading” • Uses fluoroscopic guidance report Radiology 75952or 75953 • 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

  43. Endovascular Repair of Iliac Aneurysm (34900) • Extensive notes before codes • Uses fluoroscopic guidance (75954) • 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

  44. Repair Arteriovenous Fistula (35180-35190) • Abnormal passage • Divided based on fistula type: • Congenital • Acquired/Traumatic • By site

  45. Angioplasty and Atherectomy (35450-35476) • Open or percutaneous by vessel • Transluminal angioplasty: Catheter passed into vessel and stretched • Code per vessel • Stent placement reported separately • Code imaging separately

  46. 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

  47. Bypass Graft, Vein • Code by type of graft and vessels being used to bypass • Example: 35506, Bypass graft, with vein; carotid-subclavian orsubclavian-carotid • Graft attached to carotid and to subclavian, bypassing a defect of subclavian

  48. Vascular Injection Procedures (36000-36522) • Divided into: • Intravenous • Intra-Arterial—Intra-Aortic • Venous (Cont’d…)

  49. Vascular Injection Procedures (36000-36522) (…Cont’d) • Used for many procedures, includes: • Local anesthesia • Introduction of needle • Catheter • Injection of contrast material • Pre- and post-operative care • Example: Injection of an opaque substance for venography

  50. Transcatheter Procedures (37184-37216) Arterial mechanical thrombectomy (37184- 37186) • Removal arterial thrombus by mechanical device • Used to report a variety of transcatheterprocedures Venous mechanical thrombectomy (37187, 37188) • Removal venous thrombus by means of a mechanical device

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