[Music] Okay. So, I'm going to do the next topic. This is was very interesting. I I really got into giving some visual aids and I was said, "Oh, shoot. I'm not going to have time to do that." But this one's very meaty. So, um we'll be doing more. I think it's better to do it more thoroughly than to to rush through. Uh so this question was I need understanding on how to approach this case per guidelines there is a code first 36216 and 217 and then 36225 and 226 on the answer sheet I'll show you the codes what's the proper way to report these should I code each additional that's your 36218* 4 because of the bilaterals that we'll go into or should I code 36218* 2 because of the other areas explored card. So, I'm going to show you how to go through when you're doing these first order branches, second order, third order, etc. So, let's find my and while she's changing that, I'm looking at what it is. And if you don't know, costto means rib. So, prostoervical. So, cervical, spine, rib. If you want more information, if those didn't if you didn't know that, you probably need to take our anatomy course. Yep. Good suggestion. Okay, so this one was requested by Beverly. She's a CCO club member and she has been peppering me with questions or I say me because I've been answering them and I said I feel like she's giving me homework. So real quick too, Lorine, this is a good time to tell people that we don't want to do the work for you. And so Beverly go went in and she said, "This is what I'm thinking." Just like on those others, you know, I'm thinking these am I right or you know? Oh, and it's more for a tiebreaker. My coworker says this, I think that or the provider is saying this, but I think it's this, you know, it's basically getting a tiebreaker. And that's that and that is helps for teaching. So, we can can see how their mind is thinking to help, you know, straighten them out. All right. So, this is for question. I put the codes here so we could kind of look at it. This is what I need to do. I'm a very visual learner. I have to highlight things and you know look at this how we teach people to pass the exam compare and contrast the codes what's the difference right so you can see the 36216 from her question is for a selective catheter placement in the arterial system the initial second order and what's the family it's the thoracic or brachio syphalic branch the 217 is the initial third order or more selective fourth, fifth, you know, however, how however many splits the vessel takes. Same family though. So you got initial second order, initial third order, or more selective. Then 218 is the additional second, third, and beyond, but it's the like an add-on code. It's the additional. And then the 225 and 226 from her question. This is for the subclavian or inanimomate artery. And then the 226 is for the vertebral artery. So keep those in mind. And she didn't really give me like the OP report. She has in the past and I prefer those, but I know it's a pain to have to redact. So So basically she gave us a summary. So they started off with an introduction of the needle and catheter into the right common femoral artery. I'm going to show you some pictures so don't go like I can't visualize this blah blah blah. Um actually I'm going to come back up here as we need to refer to it but let me just take you to this picture here because this is the actual breakdown of what's going on in your CPT manuals. A lot of people don't know this if you're if you're not a student and you haven't become one with your manual. That's what we we we teach in our courses. You really need to get so familiar with your manual. And that's why paper manuals are really the way to learn. Once you visualize and you remember how the paper manual works using an encoder or like a find a code, then it works so much better. But the CPT manual also has a lot of great graphics and things that explain it. And there's a appendix L vascular families. So check that out in your CPT book and it will really help you with understanding these first, second, third orders. So in this one she had the right subclavian family and okay so you see where I have this number two sub subclavian right? So we we have the aortic arch and then off of that aort aortic arch which I've labeled number one is the anonymate. So that would be considered the first order and then it splits or bifurcates I'd like to call it and then we have the subclavian. So that's why it's a second order. Then off of the subclavian it's kind of hard to picture. Let me see if I can make this bigger. Oops. Hope I didn't Yeah, I messed up my slide. Oh well. Um, that's a little bit better. So, the subclavian goes all the way around, but this is where we're we're looking at. We're looking for this costto cervical trunk and it comes off right here. So, we went first order, second order. So, this would be a third order. Then they're coming in and they're injecting dye. So, just picture like the catheter traveling along. So it comes first, second, and oh, now it's injecting dye here. And it's pulling back out, and it's injecting dye in another third order. So it's two third orders is what's going on here. So let me try and put my slide back the way I had it. So initial third order for the right costto cervical, that's your your 36217. Then the additional third order for this thyroervical that's going to be your first unit of 218. Then going on the other side the subclavian family we have an initial costto cervical one. So that is a second order branch. So that gets your 3 6 2 1 6 because it's your initial second order. And then we had the left thyroervical. So that becomes your next or your additional 36218. So now we have two units of our 36218. Then they also did the bilateral common corateeds which are right here and there's a special code for that 36223 and we put a 50 and then the vertebrals 36226 and we put a 50 because they were bilateral as well. So that's one way to visualize it. Use the picture in your CPT book in appendix L. And then another way to visualize it is if you're like a table kind of person they have this table. If you're coming off the thoracic artery and because you're reading the op report, you got to you want to find the path and visualize it, trace it out. People that are VI coders, they have all the charts from like Dr. Z and you know they they're laminated. Sometimes they'll use those wipe on wipe off markers. So this is your inanimate. So that's your first order branch. And see on the top it says first order. And then off of that for our particular case we came through the subclavian. That's our second order. And then this branches into 1 2 3 four different vessels. We our provider worked on these two. The costtoervical and the thyroervical. And they're both third orders. So that's why we're we're when we look at the codes, we're doing the initial third order 217 and then an additional second or third and beyond. It doesn't matter if it was second, third, or fourth or whatever for the additionals. You tracking with me? Give me feedback. They are super quiet. They are entranced. But I really think they appreciate because I know I do the two different ways to look at it. The visual of the structure itself and that table. Some people that that I'm sure aligns with a lot of people too. Well, sometimes on these images you're like squinting and you're looking is that coming off of this or not. So if you go to the table, they tell you like right, all right, here's my here's my Okay, that's branching off of this which is branching off of that. Got it. Yeah. So that that helps a lot. Then of course they did the andrography, the imaging because you don't just put the catheter in there to squirt dye and walk away. You take a picture. Um that gets reported separately for each vessel that's studied. So we had one, two, three, four, five. So there five units. And the note here is the right vertebral and common curate lack documented angiograms. That's why you're probably thinking, but wait, you had the codes for but if you didn't document it, it wasn't done. So that was what we noticed for these. And then ultrasound guidance was mentioned. So that's your 76937 professional component only to um get the physician paid for their work. Well, I thought it would take a lot longer to do that. No. Well, that's pretty doing those two different ways to do that. I think one of the takeaways is that it gets very confusing because you're dealing with multiple codes. But if you do this type of work, which again, if you're coding these, you're doing multi, you know, you're doing these all day. And it becomes you get them memorized, you know. So it yes it's a lot of codes but so is knowing a lot of people's phone numbers you know which I guess isn't a really good because now we don't know people's phone numbers because we have cell phones but again you you once you get the feel for it this is not intimidating at all and then as Loren said you can go to Z Health and you can literally do use they have all of these great tools to help you uh let's See, I'm gonna I'm gonna share something. Oh, did we have a question? Yeah, Christopher just says, "I struggle with the guides. Thank you work for working through the table." I again I think that's is really helpful. Me, for myself, I want to see the anatomic structure because that's what I know. But if you don't if you're not into that, having that listed out that the and knowing one leads to the other then leads to the other, this is a great way to get familiar with that anatomy and the verbiage because this is the way it looks on the report. The report doesn't have the diagram. No, I know the names of the vessels and stuff like that, but so this um vascular family, if I look at that, that confuses me when I look at this. But if I go look at the diagram and you you say, "Oh, yeah, that's that vessel, that's that vessel." So, uh it's important to to know what works for each person. And here's a tip. First order can change based on where you start. So, be careful of that. So in this one, this is the most common coming off of the aorta. So anything coming off the aorta is the first order branch. That's commonly how it's done. But you could start in a second order branch. It's possible. So be aware of that. So this is the appendix L and it's a vascular branching model that assumes the aorta or the venneava pulmonary artery or portal vein is the starting point of catheterization. Accordingly branches have been categorized into first, second, third and beyond. Note that this categorization does not apply for instance if a femoral or corateed artery were catharized directly because that then becomes your starting point and anything off of that is first, second, third. So common branching patterns of typical anatomy are shown in the charts and illustrations. No specific coding instruction should be inferred. End users must determine how to best code any specific procedure based on variant anatomy and different vascular access points relative to the vessels selectively catheterized. So you might have to go through the subclavian to get to these you know we did the thyro cervical and the costtoervical but if they didn't stop here and inject die then we're not coding this. This is just the path to get to these end points. We're coding the end points where they injected the die. Oh, reverse, pull out, go into the other third order. Okay, inject die. So, those are our two end points that we're looking to have codes for. And you can now get see videos of these done. And so, it might be it's kind of like all in black and white, but that may help you link your brain to the codes and some of this verbiage. A lot of times they're talking while they're doing that. I would encourage you to go out and look for those. Uh I don't know if they're on YouTube or or o I used to go to or live literally O and R.live. And so that may help it click for you. So here's a question. Get your thinking cap on. So here for the right subclavian, it's a second order coming off the thoracic aorta. Now we come down here. coming off the thoracic aorta. Left subclavian is a first order. Why is that? So, if we go to our picture, I think it's on this one. Was it here? Now, I can't remember. Yes, here it is. Um, if you look at these clavian, look at the anatomy, how it's different coming off the aorta on the right. I know in the picture it's on the left it gets confusing but it this is considered a first order piece and then it splits. That's why this is a second order on the right but this subclavian there is nothing like that. So it is a first order that cool think of the tree and a tree limb always you know forks that's what they're looking for those forks in the road. Yeah. So keep that in mind. Hopefully that that will help you if um this is one that scares you know new students and you just just think of branches on a tree and you come off the trunk. Think of that as a aorta. And once you can get the main trunk analogy and the first branch that comes off the trunk and then where it splits that becomes second order. You follow one of the pass and where wherever it splits that now becomes third order. So once you can do the coding from there, then you can handle if you get a different starting point. Okay, where's first, second, third, and so on and so forth. It's intimidating for me because I am not a CT CPT lover. However, I know the anatomy and I really love the anatomy, so that kind of makes up for it. But that is that is a niche that some people just fall in love with and there is a huge demand for interventional radiology or IR coders if that's an area that you would like to get into. You can start working in cardiology and then you know get into they get paid very very well. It takes a while to to build up your skills, but it is a fun area to be in, and people appreciate others who have that skill. Looking for medical coding, medical billing, and risk adjustment education? Learn more at cco. us. [Music]