Slide 1 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. CHAPTER 21 CARDIOVASCULAR SYSTEM

Slide 2 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiovascular System CV coding may require codes from: Radiology Medicine Surgery (Cont’d…)

Slide 3 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiovascular System (…Cont’d) Radiology: _________ studies Medicine: __________ and percutaneous Surgery: _____ and percutaneous Diagnostic Nonsurgical Open

Slide 4 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiology Coding Terminology _______ : 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…) Invasive

Slide 5 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiology Coding Terminology (…Cont’d) __________: Procedures that do not break skin –Example: Electrocardiogram (Cont’d…) Noninvasive

Slide 6 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiology Coding Terminology (…Cont’d) ______________ (EPS): Study of electrical system of heart ―Example: Study of irregular heartbeat (_________) (Cont’d…) Electrophysiology arrhythmia

Slide 7 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiology Coding Terminology Nuclear (…Cont’d) ______ Cardiology: Diagnostic and treatment specialty, uses radioactive substances for cardiac conditions Example: MRI

Slide 8 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiovascular in Surgery Section Codes for procedures: –Heart/Pericardium (___________) Pacemakers, valve disorders –Arteries/Veins (___________)

Slide 9 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Heart/Pericardium ( ) Both ___________ and open procedures Extensive notes throughout Frequent changes with medical advances (Cont’d…) percutaneous

Slide 10 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Heart/Pericardium ( ) (…Cont’d) Examples of Heart/Pericardium subheadings: –Pericardium –Cardiac Tumor –Pacemaker or __________ _________ Defibrillator Cardioverter-

Slide 11 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Heart/Pericardium Categories Pericardiocentesis _______________: Percutaneous withdrawal of fluid from pericardial space Excision of Cardiac Tumor: Open surgical procedure for removal of tumor on heart

Slide 12 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Pacemaker or Pacing Cardioverter- Defibrillator ( ) Figure: 21.7 A, Single pacemaker insertion. B, Dual chamber pacemaker. C, Biventricular pacemaker. (B from Lewis SL, Dirksen SR, Heitkemper MM, Bucher L, Camera IM: Medical-Surgical Nursing: Assessment and Management of Clinical Problems, ed 8, St. Louis, 2011, Mosby.) electrical Devices that assist heart in ________ function (Cont’d…)

Slide 13 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Pacemaker or Pacing Cardioverter- Defibrillator ( ) (…Cont’d) Divided by where electrodes (leads) placed, ________, 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. approach Figure: 21.5

Slide 14 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Pacemaker or Pacing Cardioverter- Defibrillator ( ) (…Cont’d) Placed: –Atrium (_____ chamber (uses 1 lead) –Ventricle (_____ chamber) –Both (___ chamber (uses 2 leads) –__________, both ventricles and right atrium (__ leads) (Cont’d…) From Miller RD, editor: Miller's Anesthesia, ed 7, Philadelphia, 2010, Churchill Livingstone. single dual Biventricular 3 Figure: 21.6

Slide 15 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Pacemaker or Pacing Cardioverter- Defibrillator ( ) (…Cont’d) Approach: –________: Open procedure to place on heart –__________: Through vein to place in heart (Cont’d…) Epicardial Transvenous

Slide 16 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Pacemaker or Pacing Cardioverter- Defibrillator ( ) (…Cont’d) Type of Service –Initial placement or replacement of all or part –Number of _____ placed (Cont’d…) leads

Slide 17 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Pacemaker or Pacing Cardioverter- Defibrillator ( ) (…Cont’d) Patient record indicates revision or replacement Usual follow-up period 90 days (_____ period) Use ___ to indicate return to operating room within global period global -78

Slide 18 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Electrophysiologic Operative Procedures ( ) Surgeon repairs defect causing abnormal rhythm Endoscopy Procedure –Without CP Codes based on reason for procedure, approach, and if CP bypass used

Slide 19 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Electrophysiologic Operative Procedures ( ) Chest opened to full view—Incision –______________ (CP) bypass usually used Cardiopulmonary

Slide 20 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Patient-Activated Event Recorder (33282, 33284) Also known as cardiac event recorder or ____ recorder Internal surgical implantation required Divided based on ______ being implanted or removed loop device

Slide 21 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiac Valves ( ) 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

Slide 22 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Coronary Artery Bypass Graft CABG performed for coronary arteries severely clogged (atherosclerosis) (Cont’d…) Figure: 21.8A

Slide 23 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Coronary Artery Bypass (…Cont’d) Determine what was used in repair: –Vein (_____-33516) –Artery (33533-_____) –Both artery and vein (_____ and _____) (Cont’d…) From Monahan FD, Neighbors M: Medical-Surgical Nursing: Foundations for Clinical Practice, ed 2, Philadelphia, 1998, Saunders Figure: 21.9

Slide 24 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Coronary Artery Bypass (…Cont’d) Number of bypass grafts performed and if ____ and ______ grafts are used –Example: Three venous grafts veinarterial

Slide 25 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Venous Grafting Only for Coronary Artery Bypass Graft Codes –Divided based on number of grafts being placed Procurement of _________ vein included in procedure (not coded separately) when retrieved through open incision Code reported separately –Endoscopic, surgical, video-assisted harvest of vein(s) –______ code, do not append -51 saphenous Add-on

Slide 26 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Arterial Grafting ( ) Divided based on number of _____ 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…) grafts

Slide 27 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Arterial Grafting (…Cont’d) 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

Slide 28 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Combined Arterial-Venous Grafting 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 (Cont’d…)

Slide 29 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Combined Arterial-Venous Grafting (…Cont’d) Procuring saphenous vein included, if open retrieval Endoscopic harvest is reported with _____ If reoperation report with _____ –No -51, add-on codes Never used alone Add-on codes always used with ______ Grafting codes ( ) Arterial-Venous codes report only ______ graft portion of procedure Arterial venous

Slide 30 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Endovascular Repair of Descending Thoracic Aorta ( ) 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) _________ (endoprosthesis) reinforces weakened area Stent-graft

Slide 31 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Arteries and Veins Subheading ( ) Only for __________ 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 (Cont’d…) noncoronary

Slide 32 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Arteries and Veins ( ) (…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. Figure: 21.14

Slide 33 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Arteries and Veins ( ) (…Cont’d) __________: Direct placement without further manipulation ________ : Place and then manipulate into further order(s) Nonselective Selective

Slide 34 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Catheter Placement Example __________: 36000, Introduction of needle into vein _______: 36012, Placement of catheter into second order venous system Nonselective Selective

Slide 35 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Vascular Families Are Like a Tree Main branch— ____ order (tree trunk) ______ order branch (tree limb) ____ order branch (tree branch) Appendix _, CPT, Vascular Families –Lists first, second, third, and beyond third order branches –Assumption that starting point is catheterization of ____ first Second Third L aorta

Slide 36 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Brachiocephalic Vascular Family Report ______ extent of catheter placement in a vascular family Figure: farthest

Slide 37 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Embolectomy and Thrombectomy ( ) _______: Dislodged thrombus ________: Mass of material in vessel, in place of formation Balloon removal: Threaded into vessel, inflated under mass, pulled out with mass Embolus Thrombus

Slide 38 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Embolectomy Removal of embolus Figure: 21.16

Slide 39 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Venous Reconstruction ( ) Types of repair: –Valve of femoral vein –Vena cava –Saphenopopliteal vein anastomosis

Slide 40 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 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…)

Slide 41 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Aneurysm (…Cont’d) Repair by removal, bypass, or ___ 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 coil

Slide 42 Copyright © 2014 by Saunders, an imprint of Elsevier Inc Extensive notes preceding codes—“must reading” Uses fluoroscopic guidance, report Radiology _____ or Includes access, catheter manipulation, balloon angioplasty, stent placement, site closure Other procedures performed at same time are coded _________ Verify bundled codes in CCI edits Endovascular Repair of Abdominal Aortic Aneurysm separately

Slide 43 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Endovascular Repair of Iliac Aneurysm (34900) Extensive notes before codes Uses fluoroscopic ________ (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 guidance

Slide 44 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Repair Arteriovenous Fistula ( ) Abnormal passage Divided based on fistula type: –Congenital –Acquired/_________ –By site Traumatic

Slide 45 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Angioplasty ( ) Open or percutaneous by vessel ____________________: Catheter passed into vessel and stretched –Code per vessel –Stent placement reported separately –Code imaging separately Transluminal angioplasty

Slide 46 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Noncoronary Bypass Grafts ( ) Divided by: –Vein –_____ 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 In-Situ

Slide 47 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Bypass Graft, Vein Code by type of graft and vessels being used to bypass –Example: 35506, Bypass graft, with vein; ______________ or subclavian-carotid –Graft attached to carotid and to subclavian, bypassing a defect of subclavian carotid-subclavian

Slide 48 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Vascular Injection Procedures ( ) Divided into: –Intravenous –Intra-Arterial—Intra-Aortic –______ (Cont’d…) Venous

Slide 49 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Vascular Injection Procedures ( ) (…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

Slide 50 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Transcatheter Procedures ( ) Arterial mechanical thrombectomy (37184-_____) Removal arterial thrombus by mechanical device Used to report a variety of ___________ procedures Venous mechanical thrombectomy (_____, 37188) Removal of venous thrombus by means of a mechanical device transcatheter

Slide 51 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiovascular in Medicine Section Services can be: –Invasive or __________ –Diagnostic or _________ (Cont’d…) noninvasive therapeutic

Slide 52 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiovascular in Medicine Section (…Cont’d) Subheadings: –CoronaryTherapeutic Services and Procedures –Cardiography –Cardiovascular Monitoring Services –Implantable and Wearable Cardiac Device Evaluations –Echocardiography (Cont’d…)

Slide 53 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. CV in Medicine Section (…Cont’d) Cardiac Catheterization _________________________ (EP) Procedures/Studies _____________________ (PAD) Rehabilitation Noninvasive Physiologic Studies and Procedures Other Procedures Intracardiac Electrophysiologic Peripheral Arterial Disease

Slide 54 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Therapeutic Services and Procedures ( ) Types of services: –Cardioversion –Infusions –Thrombolysis –Catheter placement (Cont’d…)

Slide 55 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Therapeutic Services ( ) (…Cont’d) Many groups of codes are divided by: –______ (e.g., balloon, blade) –_______ (e.g., aortic or mitral valve) –_______ (e.g., single or additional vessels) Method Location Number

Slide 56 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiography and Cardiovascular Monitoring Services ( ) Types of service: –Stress tests –_____ monitor 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. Holter Figure: 21.22Figure: 21.24

Slide 57 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiography and Cardiovascular Monitoring Services ( ) Electrocardiogram Separate codes for global procedure and components (professional and technical) –See 93000, 93005, 93010

Slide 58 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Holter Report Used to identify cardiac __________ Figure: arrhythmias

Slide 59 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Implantable and Wearable Cardiac Device Evaluations ( ) New codes in 2009 Category notes include definitions and instructions Extensive notes

Slide 60 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Echocardiography ( ) Noninvasive diagnostic procedure: Ultrasound detects presence of cardiac or vascular disease Figure: 21.27

Slide 61 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiac Catheterization ( ) Used to identify valve disorders, abnormal blood flow Many _______ services in catheterization codes bundled (Cont’d…)

Slide 62 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiac Catheterization ( ) (…Cont’d) Example: –Introduction –Positioning/Repositioning of catheter –Pressure readings inside heart or vessels –Blood samples –Rest/Exercise studies –Final evaluation and report Many codes ___ exempt -51

Slide 63 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 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 ______-______, cath for congenital anomalies require ______ or ______ (imaging/injection) From LaFleur Brooks M: Exploring Medical Language: A Student- Directed Approach, ed 7, St. Louis, 2009, Mosby

Slide 64 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Intracoronary Brachytherapy (92974) New Procedure uses radioactive substances to destroy restenosis of coronary vessel Patients have had ____ placed in coronary vessel Stent “________” (reformation of plaque) (Cont’d…) From Zipes DP, editor: Braunwald's Heart Disease, ed 7, Philadelphia, 2005, Saunders Brachytherapy delivery system for coronary artery stent restenosis stent From Zipes DP, editor: Braunwald's Heart Disease, ed 7, Philadelphia, 2005, Saunders Figure: restenosis

Slide 65 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Intracoronary Brachytherapy (…Cont’d) Cardiologist: Places guidewire and _______ ________ oncologist: Places radioactive elements catheter Radiation

Slide 66 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Intracardiac Electrophysiologic Procedures/Studies (_____-_____) 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

Slide 67 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. EP System of Heart Electrical conduction system (Cont’d…) Figure: 21.30

Slide 68 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. EP System of Heart (…Cont’d) Electrical recording codes divided based on ______ of recording device Example: Bundle of His or right ventricle location (Cont’d…)

Slide 69 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. EP System of Heart (…Cont’d) Pacing: Temporary pacing to stabilize beating of heart –Example: Intraventricular or intra-arterial pacing

Slide 70 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Peripheral Arterial Disease (PAD) Rehabilitation (93668) Rehabilitation sessions: __-60 minutes Use of motorized treadmill/track to build patient’s CV endurance Supervised by exercise __________ or _____ 45 physiologist nurse

Slide 71 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Noninvasive Physiologic Studies and Procedures ( ) Category contains codes for services such as: –______________: Recordings of changes in size of body part when blood passes through it (Cont’d…) Plethysmography

Slide 72 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Noninvasive Physiologic Studies and Procedures ( ) (…Cont’d) Electronic Analysis: Checks electronic function of devices, such as pacemakers (Cont’d…)

Slide 73 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Noninvasive Physiologic Studies and Procedures ( ) (…Cont’d) Ambulatory Blood Pressure Monitoring: _________ basis over 24-hour period ___________: Visual recordings of temperature of body From Forbes CD, Jackson WF: Color Atlas and Text of Clinical Medicine, ed 3, 2003, Mosby. Outpatient Thermograms

Slide 74 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiovascular in Radiology Section Divided complete procedures into two components: ________ and __________ (Cont’d…) Technical Professional

Slide 75 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiovascular in Radiology Section (…Cont’d) Radiology Section, Heart ( ), and Aorta/Arteries ( ) subsections (Cont’d…)

Slide 76 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiovascular in Radiology Section (…Cont’d) Example: Angiography –________ component angiography—remains in Radiology Section –__________ component injection—moved to Surgery Section (Cont’d…) Technical Professional

Slide 77 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cardiovascular in Radiology Section (…Cont’d) Complete angiography requires ________ code and ______ code Reflects common practice of cardiologist performing injection and radiologist reporting angiography results radiology surgery

Slide 78 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Contrast Material Often radiologic procedures use _______ material to improve image Many codes have contrast material bundled into service –“With contrast” or “with or without contrast” Only _______ contrast qualifies (Cont’d…) contrast injected

Slide 79 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Contrast Material (…Cont’d) Contrast not included in description, used in procedure; code both contrast material and _______ separately Physician performs injection procedure in hospital outpatient department; use ___ for professional component only injection -26

Slide 80 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. A Component Coding Example Two physicians (cardiologist and radiologist from same facility) perform angiography of third order brachiocephalic artery with contrast Cardiologist placing catheter (36217)— Surgery Section (Cont’d…)

Slide 81 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. A Component Coding Example (…Cont’d) Radiologist performs angiography (Supervision and interpretation) (75658), Radiology Section Supply of contrast material (_____), Medicine Section 99070

Slide 82 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Conclusion CHAPTER 21 CARDIOVASCULAR SYSTEM