Cardiovascular Systems CPT Disclaimer CPT copyright 2012 American

Cardiovascular Systems

CPT® Disclaimer CPT® copyright 2012 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT® is a registered trademark of the American Medical Association. Cardiovascular Systems 2

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-9 -CM and HCPCS Level II codes and coding guidelines as they apply to this system • Supply examples and review material to improve your application of the above concepts Cardiovascular Systems 3

Circulatory Systems • Systemic Circulatory System – Blood Vessels • Arteries • Veins • • Pulmonary System Coronary System Portal System Lymphatic System Cardiovascular Systems 4

Cardiovascular Systems 5

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 Cardiovascular Systems 6

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 Cardiovascular Systems 7

Anatomy • Lymphatic System – Lymph – fluid collected – Lymph nodes – small collections of lymphatic tissue through which lymph fluid is filtered – Lymphocytes – cells of the immune system • Right lymphatic duct drains into right subclavian vein • Thoracic duct drains into left subclavian vein – Both subclavian veins empty into the inferior vena cava Cardiovascular Systems 8

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 Cardiovascular Systems 9

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 Cardiovascular Systems 10

Circulations • Portal System – Directs blood from the intestines to the liver – Liver processes the blood before the blood continues on to the heart Cardiovascular Systems 11

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 Cardiovascular Systems 12

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 Cardiovascular Systems 13

Heart • Four (4) Chambers – Two atria – Two ventricles • Three (3) layers – Endocardium – Myocardium – Epicardium • Pericardial sac (double-walled membrane) – Visceral pericardium – Parietal pericardium Cardiovascular Systems 14

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 Cardiovascular Systems 15

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 Cardiovascular Systems 16

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 Cardiovascular Systems 17

ICD-9 -CM Coding • • • Chapter 01: Infectious and Parasitic Diseases Chapter 02: Neoplasms Chapter 07: Diseases of the Circulatory System Chapter 14: Congenital Anomalies Chapter 16: Signs, Symptoms, and Ill-Defined Conditions Cardiovascular Systems 18

Diseases of the Circulatory System • Acute rheumatic fever (390 -392) – Symptoms include fever, joint pain, lesions of the heart, blood vessels and joint connective tissue, abdominal pain, skin changes, and chorea • Chronic rheumatic heart disease (393 -398) – Persistent inflammation of heart lining due to rheumatic heart disease. Cardiovascular Systems 19

Cardiac Cycle Blood pressure • Measurement of the pressure of blood exerted within the blood vessels - Sphygmomanometer 120/80 mm Hg 120 = Systole 80 = Diastole Cardiovascular Systems 20

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) Cardiovascular Systems 21

ICD-9 -CM: Hypertension • Hypertensive Disease – – 401 402 403 404 Essential hypertension Hypertensive heart disease Hypertensive chronic kidney disease Hypertensive heart and chronic kidney disease Guidelines I. C. 7. a. 1. through 11. Hypertension Table in alphabetic index ICD-9 -CM Many guidelines found in the Tabular List for these categories Cardiovascular Systems 22

ICD-9 -CM: Ischemic Heart Disease • 410 Acute myocardial infarction – 5 th digit 0 Episode of care unspecified 1 Initial episode of care Regardless of the number of transfers during initial care 2 Subsequent episode of care (8 weeks or less) STEMI (ST elevation) NSTEMI (non-ST elevation) Cardiovascular Systems 23

ICD-9 -CM: Ischemic Heart Disease • 411 Other acute and subacute forms of ischemic heart disease • 412 Old myocardial infarction • 413 Angina pectoris • 414 Other forms of chronic ischemic heart disease Use 414. 01 CAD/arteriosclerosis when there is no history of coronary artery bypass surgery. Cardiovascular Systems 24

ICD-9 -CM: Ischemic Heart Disease • 414. 8 Other specified forms of chronic ischemic heart disease – Chronic coronary insufficiency – Ischemia, myocardial (chronic) – Any condition classifiable to 410 specified as chronic, or presenting with symptoms after 8 weeks from date of infarction Use 411. 89 for acute coronary insufficiency Cardiovascular Systems 25

ICD-9 -CM: Ischemic Heart Disease Example: A cardiac catheterization is scheduled for a patient who had an inferoposterior wall infarction 12 weeks ago. She is still having chest pain, which radiates to the left arm related to mild exertion. Look in the Index to Diseases under Disease, diseased/heart/ischemic 414. 9. Check the Tabular List for 414. 8. Because the disease is specified, code 414. 8 is correct, not 414. 9. Cardiovascular Systems 26

Occlusion of Arteries • Occlusion of arteries 414. 2 x Chronic total occlusion of coronary artery, when coronary artery is 100 percent occluded for several months. 440. 4 Chronic total occlusion of artery of the extremities, when there has been total artery occlusion of the arm or leg. 411. 81 Acute coronary occlusion without myocardial infarction. Use 411. 81 for occlusion caused by debris. NOTE: 414. 2 x and 440. 4 and can only be secondary codes Cardiovascular Systems 27

ICD-9 -CM: Aneurysm • 414. 1 – – Aneurysm and dissection of heart 414. 10 Aneurysm of heart (wall) 414. 11 Aneurysm of coronary vessels 414. 12 Dissection of coronary artery 414. 19 Other aneurysm of heart Cardiovascular Systems 28

ICD-9 -CM: Heart Disease • • • 415 – 417 Diseases of pulmonary circulation 420 Acute pericarditis 421 Acute and subacute endocarditis 422 Acute myocarditis 423 Other diseases of pericardium 424 Other diseases of endocardium 425 Cardiomyopathy 426 Conduction disorders 427 Cardiac dysrhythmias 428 Heart Failure 429 Ill-defined descriptions and complications of heart disease Cardiovascular Systems 29

Congestive Heart Failure • Congestive heart failure – Not an inherent component of systolic or diastolic heart failure. – When CHF is list with the above, assign two codes • Systolic, diastolic, or combined systolic/diastolic heart failure • CHF, unspecified – 428. 0 Cardiovascular Systems 30

ICD-9 -CM: Congenital Anomalies • 745 Bulbus cordis anomalies and anomalies of cardiac septal closure • 746 Other congenital anomalies of heart • 747 Other congenital anomalies of circulatory system Cardiovascular Systems 31

Signs & Symptoms • 785 Symptoms involving cardiovascular system – – – – 785. 0 Tachycardia, unspecified 785. 1 Palpitations 785. 2 Undiagnosed cardiac murmurs 785. 3 Other abnormal heart sounds 785. 4 Gangrene 785. 5 X Shock without mention of trauma 785. 6 Enlargement of lymph nodes 785. 9 Other symptoms involving cardiovascular system • 786. 5 X Chest pain – 786. 50 Chest pain, unspecified – 786. 51 Precordial pain – 786. 59 Other Cardiovascular Systems 32

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 Cardiovascular Systems 33

CPT Coding • • • Surgical Section - Cardiovascular System — 33010 -37799 Heart and Pericardium – 33010 -33999 Radiology Section – Heart – 75557 -75574 – Vascular Procedures – 75600 -75989 – Diagnostic Ultrasound (various CPTs) – Radiologic Guidance – 77001 -77022 – Nuclear Medicine Diagnostic, Cardiovascular System – 78414 -78499 Medicine Section – Cardiovascular – 92920 -93799 – Noninvasive Vascular Diagnostic Studies – 93880 -93998 Cardiovascular Systems 34

Pericardium • Pericardiocentesis (33010 -33011) – Diagnostic test – Cardiac tamponade – Radiological supervision and interpretation (76930) • Pericardotomy for removal of clot/FB (33020) – Add 32658 by thoracoscopy • Pericardial window (33025) – (For thoracoscopy [VATS] pericardial window, use 32659) Cardiovascular Systems 35

Pacemakers/Defibrillators (33202 - 33249) • 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” Cardiovascular Systems 36

Pacemaker or Pacing Cardioverter-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. Cardiovascular Systems 37

Pacemaker or Pacing Cardioverter-Defibrillator • 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 a pacing cardioverter-defibrillator pulse generator • Single lead system (33262), dual lead system (33263) or multiple lead system (33264) Radiological supervision and interpretation related to pacemaker or cardioverterdefibrillator procedure is included in 33206 -33249. Cardiovascular Systems 38

Pacemaker or Pacing Cardioverter-Defibrillator • Guidelines – Insertion of new or replacement of permanent pacemaker with transvenous electrodes(s) (3320633208) – Insertion of pacing cardioverter-defibrillator pulse generator with single, dual, or multiple leads (3324033231) Cardiovascular Systems 39

Pacemaker or Pacing Cardioverter-Defibrillator • 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. 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverterdefibrillator pulse generator (including revision of pocket, removal, insertion, and /or replacement of existing generator) 33225 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter- defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (When epicardial electrode placement is performed, report 33224 in conjunction with 33202, 33203) Cardiovascular Systems 40

Pacemaker or Pacing Cardioverter-Defibrillator Patient underwent removal of a complete dual pacemaker system. A dual cardioverter-defibrillator system was placed with two transvenous electrodes, along with a biventricular electrode with use of fluoroscopy. 33249 33235 -51 33225 33233 -51 Insertion of pacing cardioverter-defibrillator leads/generator Removal dual lead system electrodes Biventricular pacing electrode Removal dual system pacemaker generator Cardiovascular Systems 41

Electrophysiologic Operative Procedures • Incision (33250 -33261) – Operative tissue ablation codes 33254 -33256 are only to be reported when there is no concurrently performed procedure that requires median sternotomy or cardiopulmonary bypass – Use add-on codes 33257 -33259 for operative tissue ablation performed at the time of other cardiac procedures. • Endoscopy (33265 – 33266) Cardiovascular Systems 42

Heart (Including Valves) and Great Vessels • 33300 -33335 – repair of cardiac wound and repair of great vessels • Great vessels: – – – Superior vena cava Inferior vena cava Pulmonary artery Four pulmonary veins Aorta Cardiovascular Systems 43

Cardiac Valves (33361 -33478) • Transcatheter aortic valve replacement (TAVR)/Transcatheter aortic valve implantation (TAVI) (33361 -33369) – 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 0318 T for transapical approach (eg, left thoracotomy) Cardiovascular Systems 44

Cardiac Valve Procedures • • Aortic Valve (33400 -33417) Mitral Valve (33420 -33430) Tricuspid Valve (33460 -33468) Pulmonary Valve (33470 -33478) Cardiovascular Systems 45

CABG • Coronary Artery Bypass Graft – Venous (33510 -33516) – Arterial-Venous (33517 -33523) – Arterial (33533 -33536) – Reoperation (+33530) Cardiovascular Systems 46

CABG • Coronary Artery Bypass using Venous Grafting only (3351033516) – 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) Cardiovascular Systems 47

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) Cardiovascular Systems 48

CABG Combined Arterial-Venous Grafting for Coronary Artery Bypass (33517 -33530) (33533 -33536) • To report combined arterial-venous grafts, you must report two codes; – – The arterial-venous graft code (33517 -33523) The arterial graft code (33533 -33536) Add-on code 33572 Coronary endarterectomy, open Cardiovascular Systems 49

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. 33534 33517 35600 33508 2 coronary arterial grafts 1 venous graft Harvest of upper extremity artery Harvest by endoscopy Cardiovascular Systems 50

Cardiac Anomalies (33600 -33853) • Single Ventricle and Other Complex Cardiac Anomalies (3360033622) • Septal Defect (33641 -33697) • Sinus of Valsalva (33702 -33722) • Venous Anomalies (33724 -33732) • Shunting Procedures (33735 -33768) • Transposition of the Great Vessels (33770 -33783) • Truncus Arteriosus (33786 -33788) • Aortic Anomalies (33800 -33853) Cardiovascular Systems 51

Heart/Lung Transplantation • 33930 -33945 • Distinct Components of Physician Work – Cadaver donor cardiectomy with or without pneumonectomy – Backbench work – Recipient heart with or without lung allotransplantation Cardiovascular Systems 52

Cardiac Assist • Intra-aortic device (33967 -33973) – Insertion and removal codes • Ventricular assist device (33975 -33983) – Extracorporeal – Intracorporeal • Insertion • removal • Percutaneous assist device (33990 -33993) – Insertion • Arterial only • Arterial and venous with transseptal puncture – Removal – Repositioning Cardiovascular Systems 53

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 Cardiovascular Systems 54

Aneurysms Endovascular Repair of Abdominal Aortic Aneurysm (34800 -34834) • 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) • 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 Cardiovascular Systems 55

Aneurysms Direct Repair of Aneurysm or Excision (Partial or Total) and Graft Insertion for Aneurysm, Pseudoaneurysm, Ruptured Aneurysm, and Associated Occlusive Disease (35001 -35152) • Separate codes for aneurysm repair and ruptured aneurysm repair Cardiovascular Systems 56

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 35390 in conjunction with 35301 Cardiovascular Systems 57

Transluminal Angioplasty (35450 -35476) • Open – – • Renal or other visceral artery Aortic Brachiocephalic trunk or branches, each vessel Venous Percutaneous – – Renal or other visceral artery Aortic Brachiocephalic trunk or branches, each vessel Venous – Code also for catheter placement and radiologic S&I Cardiovascular Systems 58

Transluminal Angioplasty (35450 -35476) • From a right femoral artery access the catheter was advanced into the aorta. Transluminal aortic angioplasty was performed. 36200 35472 75966 -26 Placement of catheter into aorta Angioplasty aorta Radiological supervision and interpretation Look in the CPT® index for Transluminal/Angioplasty/Arterial/Radiological Supervision 75962 -75968 Catheter placement and S&I will be covered later. Cardiovascular Systems 59

Bypass Grafts • Non-coronary vessels – Vein (35500 -35572) – In-situ vein (35583 -35587) • Vein is left in native location – Other than vein (35600 -35671) – Composite Grafts (35681 -35683) • Code by type/location Cardiovascular Systems 60

Vascular Injection Procedures Endovascular Revascularization • Vascular Injection Procedures and Endovascular Revascularization will be discussed in the Interventional Cardiology/Radiology Section (IVR) Cardiovascular Systems 61

Central Venous Access (36555 -36598) • • Placed for frequent access to bloodstream Tip of catheter must terminate in the: – – – • Code by – – • Subclavian vein Brachiocephalic vein Iliac vein Inferior or superior vena cava Right atrium Procedure (insertion, repair, replacement, removal, etc. ) Tunneled or not With pump or port Patient age See CVAP Table in CPT® Cardiovascular Systems 62

CPT® • Hemodialysis (36800 -36870) – See 36147 for diagnostic studies of AV shunts for dialysis • 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 (37184 -37186) • Venous Thrombectomy (37187 -37188) • Other Procedures (37191 -37216) – Foreign body retrieval, placement vena cava filter, transcatheter embolization, stent placement, etc. Cardiovascular Systems 63

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) Cardiovascular Systems 64

Vascular Injection Procedures (36000 -36680) • 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 Cardiovascular Systems 65

Vascular Injection Procedures • Intravenous – Nonselective – venography, superior or inferior vena cava – Selective • First order • Second order • Intra-Arterial - Intra-Aortic Procedures – Nonselective – Selective Cardiovascular Systems 66

Vascular Injection Procedures Five Vascular Families: • Systemic Arterial • Systemic Venous • Pulmonary • Portal • Lymphatic Cardiovascular Systems 67

Vascular Injection Procedures • 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 (36160, 36200) – Introduction of needle/catheter arteriovenous shunt created for dialysis (36147) – Introduction of needle or intracatheter, aortic, translumber (36160) Cardiovascular Systems 68

Vascular Injection Procedures • 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. Cardiovascular Systems 69

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) Cardiovascular Systems 70

Cardiovascular Systems 71

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 2 nd or 3 rd levels catheterized in same family, use add-on code Code for each vascular family accessed Code for each vascular access – Above diaphragm (36215 -36218) • Additional second and/or third order use add-on code 36218 – Below diaphragm (36245 -36248) • • Additional second and/or third order use add-on code 36248 Pulmonary angiography involves the right and left pulmonary arteries representing two vascular families Cardiovascular Systems 72

Selective Catheterization Part 1 (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. 36246 • 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. 36216, 36216 -59 • From a right femoral access, code the selective catheterization of the right internal thoracic, and the right ulnar artery. 36217, 36218 Cardiovascular Systems 73

Selective Catheterization Part 2 – Vascular Procedures Radiology • Vascular Procedures Radiology (75600 -75989) – 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 Cardiovascular Systems 74

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 Cardiovascular Systems 75

Selective Catheterization Part 1 (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 36200 is dropped, because you only code to the highest level of catheter placement. 36245 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, 75726 -26 Cardiovascular Systems 76

Selective Catheterization Part 1 (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 Stent/Placement/Transcatheter/Intravascular 37205 -37208, 37215 -37216. 37205 Transcatheter placement of an intravascular stent(s) (except coronary, carotid, vertebral, iliac, and lower extremity arteries), percutaneous; initial vessel (For radiological supervision and interpretation, use 75960) Part 1 (surgical) 37205 Part 2 (radiological) 75960 -26 37205, 36245, 75960 -26, 75726 -26 -59. Modifier 59 indicates that the diagnostic study is completely separate from the stent placement. Cardiovascular Systems 77

Diagnostic Studies of Cervicocerebral Arteries (3622136228) • Diagnostic studies of the cervicocerebral arteries include: – Nonselective and selective arterial catheterization – Diagnostic imaging of the aortic arch, carotid, and vertebral arteries – Contrast injection – Fluoroscopy – Radiological interpretation and supervision – Closure of arteriotomy by pressure or closure device – Interventional procedures during the same session are coded separately Cardiovascular Systems 78

Diagnostic Studies of Cervicocerebral Arteries (3622136228) +36227 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 36227 in conjunction with 36222, 36223, or 36224) +36228 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 36228 in conjunction with 36224 or 36226) (Do not report 36228 more than twice per side) Cardiovascular Systems 79

Diagnostic Studies of Cervicocerebral Arteries (3622136228) • Do not report 75774 as part of diagnostic angiography of the extracranial and intracranial cervicocerebral vessels. • Report 76376 or 76377 for 3 D rendering when performed in conjunction with 36221 -36228. • Report 76937 for ultrasound guidance for vascular access when performed in conjunction with 36221 -36228. NOTE: Any time a code descriptor includes “radiological supervision and interpretation” you know that the code has a professional and a technical component. For the physician services report the code with modifier 26 to denote the professional service. Cardiovascular Systems 80

Endovascular Revascularization (3722037235) • 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) Cardiovascular Systems 81

Bundled to Endovascular Revascularization (37220 -37235) – – – Conscious sedation Vascular access Catheter placement Traversing the lesion Imaging related to the intervention (previously billed as the supervision and interpretation code for the specific intervention) – Use of an embolic protection device (EPD) – Imaging for closure device placement – Closure of the access site Cardiovascular Systems 82

Endovascular Revascularization (37220 -37235) • Iliac vascular territory codes do not include atherectomy – Use Category III codes 0234 T-0238 T for atherectomy in the suprainguinal 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 Cardiovascular Systems 83

Endovascular Revascularization (37220 -37235) From a left femoral access, a stent was placed and atherectomy was performed in the right common iliac. 0238 T Transluminal peripheral atherectomy, open or percutaneous, including S&I; iliac artery, each vessel 37221 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel, with transluminal stent placement(s) 36245 -59 First order catheterization of right common iliac Modifier 59 indicates 36245 is separate from 37221, because selective catheterization is included in 37221; however, it is not included with the atherectomy. Cardiovascular Systems 84

Endovascular Revascularization (37220 -37235) From a right femoral artery access, report stent placement in left superficial femoral artery, and angioplasty of the left popliteal artery. 37226 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. Cardiovascular Systems 85

Endovascular Revascularization (37220 -37235) 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) 37232 x 2 each additional vessel; with transluminal angioplasty Cardiovascular Systems 86

Endovascular Revascularization (37220 -37235) • 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. Cardiovascular Systems 87

• Medicine Section Cardiovascular (9292093799) 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 Cardiovascular Systems 88

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) Cardiovascular Systems 89

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 Cardiovascular Systems 90

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 Cardiovascular Systems 91

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 (93454 -93461) and injection procedures (93563 -93564) with 92920 -92944) unless diagnostic cardiac catheterization is required prior to the intervention service. See guidelines in CPT®. Cardiovascular Systems 92

Coronary Therapeutic Services and Procedures (92920 -92979) 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 Cardiovascular Systems 93

Coronary Therapeutic Services and Procedures (92920 -92979) 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, 92929 -LD Cardiovascular Systems 94

Coronary Therapeutic Services and Procedures (92920 -92979) 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, 92928 -LC, 92920 -RC, 92978, 9297959 Cardiovascular Systems 95

Monitoring Heart Activity • Cardiography (93000 – 93042) – Codes for professional component, technical component, and global • Implantable and Wearable Cardiac Device Evaluations (93279 -93299) – 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. Cardiovascular Systems 96

Echocardiography (93303 -93352) • Diagnostic ultrasound of the heart • M-mode recording – used to measure chamber dimensions and to establish the timing of events • Doppler echocardiography – records the direction and velocity of blood flow • Color-flow mapping – allows images of the blood to be displayed – Transthoracic (TTE) or esophageal (TEE) – Note congenital echo – Complete or limited study Cardiovascular Systems 97

Cardiac Catheterizations (93451 -93581) • Most common access point – femoral artery • Right or left heart catheterization? • Catheter insertion, injection(s), and imaging are combined in one code Cardiovascular Systems 98

Cardiac Catheterizations (93451 -93581) Cardiac Catheterization • 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 9345193464, 93566 -93568. Cardiovascular Systems 99

Cardiac Catheterizations (93451 -93581) • • • For cardiac catheterization for congenital anomalies, see 93530 -93533. When contrast injection(s) are performed in conjunction with cardiac catheterization for congenital anomalies, see 93563 -93568. Cardiac catheterization (93451 -93461) 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 93567. For pulmonary angiography, use 93568. Cardiac catheterization procedures have a technical and professional component Add-on codes for injection procedures are professional services; therefore, no modifier Cardiovascular Systems 10 0

Cardiac Catheterizations (93451 -93581) 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. 93461 -26, 93567 Cardiovascular Systems 10 1

Cardiac Anomalies • Septal Defect – hole in the septum (or wall) of the heart separating the atria and ventricles • Repair of Septal Defect – 93580 -93581 – Transcatheter Closure Cardiovascular Systems 10 2

Intracardiac Electrophysiological Procedures/Studies • 93600 -93662 • Percutaneous • Indications - Cardiac arrhythmias causing: • Palpitations—irregular heart beats • Syncope—loss of consciousness • Cardiac arrest Cardiovascular Systems 10 3

Intracardiac Electrophysiological Procedures/Studies • There are codes for: – – Diagnostic electrophysiologic studies Mapping Ablation Diagnostic electrophysiologic studies with ablation during the same session Cardiovascular Systems 10 4

Peripheral Arterial Disease (PAD) • Rehabilitation is reported per session • Narrowing or blockage of the arteries in the legs • Symptoms: – Cramping – Aching – Numbness Cardiovascular Systems 10 5

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 -52. 93924 describes a complete bilateral study of lower extremity arteries Cardiovascular Systems 10 6

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 Cardiovascular Systems 10 7

The End Cardiovascular Systems