[Music] welcome to the codcast podcast real world insights for your daily medical coding and billing processes and now here's your host Terry Fletcher hello everyone and welcome to the codcast podcast today my name is Terry Fletcher so we're actually going to be talking about coding today I know on the code I usually have a question that I like to respond to which always has to do with coding and then I do Veer off sometimes into published guidance you know Medicare regulation compliance and we do talk about coding obviously we have to if it's the codcast podcast but I really wanted to focus on coding today and I wanted to focus on heart caths haven't really talked about it in a long time it's my number one specialty so for anyone that is thinking of either changing Specialties or has a hard time with understanding Cardiology or even just the basics of cardiac caths I thought I'd give just some insight there without making this I don't want this to be a webinar on that I just want to have have a conversation with you on some of the things to look for within your reports if you're coding from a report hopefully you are or if you're giving getting information from your provider and you're not really sure what you're looking at then hopefully I'll be able to just give you some insight there so when we look at cardiac Cal first the definition it's a procedure used to diagnose and treat cardiovascular conditions so during a cath procedure or cardiac catherization procedure you're going to hear me shorten that word to Cath um a long thin tube and that's the catheter is inserted into an artery or vein it used to be and I mean probably before the last six years it used to be access in the groin or femoral artery area and or the brachial which was the arm but now we're seeing radial approaches which is in the arm but wrist area because you can get the patient up walking or ambulatory sooner and then they thread this through the blood vessels into the heart and using this catheter then the doctor can diagnose you know what's going on with that patient to treat possibly um disease or uh blockages or you know any kind of sclerosis problems that they're having that to open up that that artery vein or vessel so the patient is typically awake or Lucid during the procedure they're given some medications like maybe versed which is also a generic maasam um vadil and we call that moderate sedation you can code for that as well as long as you have at least documented um it's 15 minutes but if you have at least 10 minutes you've met the 15-minute threshold and you can't just say at least 15 minutes was or greater than 15 minutes don't say that your physician has to have in the report the exact amount of time that was used that they were under under their supervision monitoring that patient for the sedation even if it was a hospital nurse to be able to bill for the 99152 and you only get it once when you provide this cath in the in the uh facility setting because there's no work value on anything extra under the place of service that's not 11 um then you really just want to make sure you have that in the report remember the hospital or the facility is going to build theirs and your physician has to have in the report what they did in your actual op report they can refer to the nurses uh report after the fact but they have to put under my direct supervision what they used medication and then how much time and this just helps the patient relax and there is actually a very low risk of complication with cardiac calf and so if there is a heart problem then or even a heart attack if there's a suspect suspected problem of a blockage then that's when the patient is then forwarded or there's a conversation about the patient then having a Intervention which means we're going to open up that vessel I'm sure you've heard of Sten and angioplasties and atherectomy Etc we're not going to talk about those today I just want to talk about the diagnostic portion now one thing you do need to know when it comes to cardiac cath is that there are there is adult medicine and then which is congenital s information and then there is um okay I just got a stray dog moment here I'm sitting here I'm going to keep this on the podcast I'm recording and I'm looking at my window and two squirrels just stole a an orange off a a tree and ran with it so I said the wrong thing so I apologize for that but I'm watching these two squirrels with oranges in their mouths sorry stray squirrel moment and I'll get back to this so congenital is treating children in the Pediatric side and then you have adult medicine side so if you see anything that's talking about congenital medicine or anything like that then they have a separate set of codes and you'd have to just look at those codes specific specifically but when we talk about adult medicine so congenital would be the 93452 codes to 93461 codes we're looking at Adult Medicine which starts um when we are looking at the 93451 to 9345 let me see how far I'm going to go with this really 9345 93461 and then there's some add-on codes and things like that but again I'm just having a conversation this is not a a webinar on this sorry for my stay SC moment hopefully you'll find that amusing since it is a podcast and not a webinar but the other thing you want to look at is there's some in uh inconsistencies when people code for these Services because it can be you can be confused of what you're looking for and the the most routine heart cath is the 93458 and you put a 26 modifier on it this means you're crossing over the aortic valve you're going into the heart you may be injecting they call that a left ventriculography LV gam you know an injection into the left ventricle or you could just be measuring pressures and you can't get those pressures unless you go into the heart that's why you still get to keep the 93458 if you find something in the report and this is something you could probably at some point replay and write down you're looking for the acronym lvp and what that is is left ventricular and diastolic pressures so when there's no injection into the left ventricular or left ventricle and so there's no LV gram they call it performed um then you can support crossing over the Artic Val or going into the heart if your angiographic data or results give you pressures of that lvedp or it might just say you know LV um Ed or it might just say um Leed so just know that you're looking for left ventricular in diastolic pressure so you're measuring the hemodynamics or how stable the patient is or what's going on in that heart area and you could still have that the other code that everyone wants to code all the time is 93454 again 26 modifier now this means you stopped short of the heart you only injected the coronary arteries right and or left it could be one or the other or both but you didn't actually cross over the valve and go into the left ventricle go into the heart to to measure those pressures and sometimes this is being coded incorrectly so if you have one physician who just did the heart cath the full complete heart C 93458 and transferred the care to the interventionalist who will then probably re-inject just to see what they're looking at on the films from the previous heart cath you can't code for that you can't code the 93454 because it's no longer what we call diagnostic so it's just basically setup and geography and it's pretty clear in the CPT book that it says you can't code it for contrast injections or um to road map so to measure uh what you need for that stent you know anything like that it can only be if you're still trying to find a problem so keep that in mind anytime you're providing Services Under the catherization side okay now they're fighting over the orange I'm sorry it's just funny to me when you look out the window it's just funny I'll try not to look out the window but it's funny to me fighting over an orange two squirrels uh anyway I seriously don't have ADD but today I'm just laughing because it was just the funniest thing I've ever seen um anyway so when you get into that 93454 example of when you could code for it is let's say you had a patient at a previous left heart Cal so the full-blown 93458 on the 7th of January there was limited disease the doctor decided not to proceed with intervention sent the patient home but the patient the next day had reoccurring chest pain they had shortness of breath there was a definite concern they had high troponin levels The Physician brings the patient back to the cath lab injects in the right and left coronaries and said okay we found the occlusion in the right coronary in the distal artery and we decide to we're going to go ahead and put in a stint later that day or at the same time then you could code for it because remember you're still looking for something you're figuring out why why are they having a recurrence of those symptoms but if you did the heart cathet see on the 7th and transfer the patient that didn't needed to have a stent that day you transfer to the interventionalist and they did a reinjection um then no you can't code for it so it's think of this as kind of like EKG where the patient had you know a let's say they were in the office and had a new patient visit EKG there was definitely some changes some it was inconclusive but the doctor said you know what we're going to go ahead and do a treadmill just because we want to make sure what's going on they bring the patient back in they do an EKG as a basine before they do the treadmill you can't code for that so but if you did if your doctor saw an abnormal EKG on the same day as a new patient said uhoh take them over let's let's get that stress test right now because we may have to take them in for a cath then you could Co for it so a lot of Cardiology has to do with intent and that's just really important to to understand the concept before you go all out and start billing for things just because you find it in the report you also have to know why you did it and Cardiology is really big on that especially if you get into EP electrophysiology there the there's a lot of things there where you have to say well first what's the intent was it for apib was it for ventricular attack of cardio what was it for before we know how we we can code same thing when it comes to heart caths interventions that you can't code for it until you know why you're doing it what's the intent is it diagnostic is it for setup is it just because you're there you know you that's something that you have to be very careful of so the codcast podcast is also brought to you today by decision Health join decision Health this November for the advanced specialty coding virtual Summits dive into Orthopedics pain management and anesthesia Specialties and get the latest guidance for accurate coding billing and compliance visit code books.com events to register save $50 with coupon code ASC 2024 so as I'm get kind of getting back to the the Cardiology side of this I just want to say a couple other things make sure that you're looking at the full and complete definition of heartcast so that you know let's say your physician added a graft injection or let's say they looked at and it's not the right corner they looked at the right side of the heart and the left side of the heart remember the right and left coronary are on the left side of the heart the right side of the heart now has pulmonary and Venus or vein intervention and they're looking at possibly pulmonary hypertension so some people get that confused well they did a right and left coronary so that's a right and left heart cath no it's not right and left coronary stays with the left heart Cal but the right side of the heart and the left side of the heart now you're at right and left and there's combined codes for these Services sometimes there might be an extra code to add an injection if it's not part of the descriptor but you need to understand um really what's in the descriptor before you start kind of spitting out codes I also have several uh on demand webinars for Cardiology so please take a look at my website at Terry fletcher.nc standpoint and all of my heart cath and Cardiology webinars include the interventions as well I also wanted to shout out some new um coding Corner clients we've had a flood of new memberships especially executive memberships and for those of you that don't know what that is this is an online um question answer system so if you have questions about any specialty that we cover look at our website at Terry fletcher.nc we cover and you send us an email and we answer your question within 24 hours we can help you with um you know coding if you need it we can help you with um appeals and just getting that regulatory guidance cited Works in case you're you know your physician says well I want to do this and you're saying you can't do that but they say why not and you just say well hold on that that send me an email and then you know so we have a membership paid membership service and we just appreciate we've got some physician Clinics of Iowa we've got some power Health Indiana we've got Hattisburg in um clinic in uh Mississippi and we've got some Midwestern un University in Arizona and then we have some of our our new um clients also in Southern California so we appreciate all of you we we really love having the our memberships also if you're an executive member you get an ask me anything call every quarter and that's on zoom and we all kind of whoever's on executive membership you get together and uh you can lurk and just listen or if you have questions you want to ask live you can ask them so anyway enough of that commercial message just want to let you know that was available so I have another coding question I wanted to cover today just real quick this one was it was an interesting question because I had to really think about this and then it came up in an audit I did for Medicare and I really appreciated my CMS Insight on this because um he was like okay let me explain how this works so you'll notice on a lot of grids for the enm levels of service on the um the data element so the second element of being able to support a level of service on level two it says minimal or none so I've had providers say well if I have a minor problem and I do absolutely nothing on data then I can have a level two so you can say somebody has a big nose and then basically do nothing and do nothing on the management and they said I can have it no no no so here here's the the intent of that remember it says minimal or none so what that it means and this is CMS saying this is that if you consider that you let's say the patient comes in again with that big nose and there's a mark on it and they say oh that's nothing and they just let they let you go there is nothing but let's say they think there's maybe something there that they have to do an x-ray or they have to do you know maybe a biopsy or they have to maybe take a look closer and do maybe a scraping to to send to pathology or something like that just to make sure there's not a problem if they consider it and the patient says no you know let's not do it if you think it's okay and the doctor says you know I really am not concerned with it we can do this you know um this test if if you think we you know if you're worried but right now I just want to keep an eye on it and that's well documented that's where the minimal or none comes from it means it was considered so they also have the same um concept when it comes to considering certain management options um you know patient decided that they're not going to have surgery right now but the physician actually pushed for it and you still get credit for that surgery management risk option but in data it's the same thing you have to document what that what that consideration was patient can't just come in for something that is nothing and then because the data is says minimal or none that if you're using the none saying oh well we didn't do anything so we can just have patients come in for nothing no that's not how that works so if it and and how it was explained to me is that they wouldn't have put that as minimal or none on the same line if they said that you could do nothing it means minimal or none that you considered something basic maybe just one uh test or one um external you know lab or something one one thing you ordered and remember you have to have at least two combination of two to get to even low so if you just had one and and you decided whether you're going to do it or not or is a point of care test or you just didn't do it and it was documented that you you know maybe you wanted to or you considered it then that is where the none comes in where you considered it but just didn't do it so keep that in mind just to not just try not to give credit where credit isn't do okay so it has to be documented that there was something there okay well hopefully you found this information helpful today I know sometimes I get away from actual coding coding coding because I really like the Code cast to be all about coding billing compliance you know learning everything and not just uh you know we're going to code today so hopefully you did find that that helpful um what little bit of a tidbit as far as a a personal note so football season's up I'm so happy except the first preseason game Steelers were terrible I won't say they sucked okay yes I will yeah were terrible so let's just but we didn't have our starting quarterback which is supposed to be Russell Wilson I miss Kenny picket he's now a backup over in Philly and he did well of course he did but our backup uh Justin Phils did terrible so did our quasi I'm air quoting starters because that was not good let's just say it was not good I was like okay let's CH change the baseball now but anyway let's hope they clean it up and uh or I hope they clean it up and so we we go into the season hopeful and not just say oh we had another non losing season at you know whatever that that would be so anyway I'm excited we're getting back to football hopefully it'll get cooler soon and I hope everyone is enjoying the rest of their summer before everyone gets back to school gets back to normal routines at home and um and just don't forget that means traffic is going to increase soon so get out and do what you need to do before everyone gets back to you know what their routines are from The Fall season all right everyone make it a great day and thank you for listening to the codcast podcast for more information on medical coding billing auditing and compliance including how to hire Terry follow Terry on Twitter at Terry coder1 or visit her website at www. Terry c.net podcast producer Joe kosma music producer D sassin music [Music]