Transcript for:
Cardiology Overview and Coding

Good morning and welcome to the cardiology boot camp. My name is Kristen Robinson. I have my CPC, CPMA, CCC, CRC, and CMC. And today we're going to do a uh great overview of all things cardiology. So, let's go ahead and get into it. So our course overview for today um all guidance provided today is based on current AMA CPT guidelines and can change or be updated at any time. Additional details for the sources for which the information for today's meeting is located at the end of today's presentation. We will be covering the anatomy of the heart, conditions and diseases of the heart. Then we will do uh a coverage of diagnostic cath interventional coding pacemaker and ICD as well as EP and ablations as well as covering live examples through with walkthroughs and then we will have our closing remarks and summary for the sources of today's presentation. So I want to talk about a couple things starting out. This is something that you see a lot within the book um specifically to ICD code ICD10 uh CM coding. And the reason I'm covering this is because um a lot of the circulatory system has excludes one and excludes two notes. And we really want to make sure we have a firm understanding of the difference between the two. So excludes one notes means not coded here. That means that it indicates that the code is excluded and should never be used at the same time as the above code for the exclude one note. So that means that if you have two conditions and there is an excludes one note excluding the second condition that means they can never ever ever be coded together. So just make sure that you know the difference between an excludes one and an excludes two. Now excludes two means not included here. It means that if both conditions occur and they both occur separately, they can in fact be build together. So it indicates that the condition is excluded or it's not part of the second condition. So these can be documented um appropriately and build at the same time if they occur at the same time. So this is a great visual for how blood flows through the heart. So there are five systems related to the circulation in the human body. We have systemic, coronary, pulmonary, portal and lymphatic. So when you are starting with the blood flow through the heart, we start here at number one. Number one is where deoxxygenated blood enters through the right atrium uh from the vennea. Okay? So it comes up through here. And then number two, where you see this arrow pointing down, that's where the blood moves through the tricuspid valve into the right ventricle. Then as you see, here's number three. It goes up into number four. So number three is where the blood is pumped through the pulmonary valve into the pulmonary artery. And then number four is the pulmonary artery carries that deoxxygenated blood to the lungs to become oxygenated. So you see how it flows into number five. The oxygenated blood returns through the pulmonary vein into the left atrium which is number six right here. Blood moves through the mital valve into the left ventricle which is number seven shown here and you can see the arrow pointing down. So number seven is where the blood is pumped through the aortic valve into the aorta. Okay. So it goes in a circle. Okay. So into number eight where the aorta distributes the oxygenated blood to the rest of the body. And this repeats constantly within our body throughout the day. It's going to come in as deoxxygenated blood. It's going to flow through the heart through the ventricles through the valves. It goes out through the pulmonary valve back in through the pulmonary vein. And then it just repeats this process um uh over and over to keep the deoxxygenated and the oxygenated blood flowing throughout the body. So next we're going to be talking about the normal human heart and we're going to go through some really good information for the anatomy and physiology of the heart. So um if you all are familiar with your uh anatomy and physiology terms. So cardio is denoting the heart. For example, cardiovascular pertains to the heart and blood vessels. Cardiomegali is enlargement of the heart. uh cardiomyopathy is disease of the heart muscle. Then we have vase or vaso which pertains to the blood vessels in the heart. So you could have vascular which is relating to the blood vessels. Vaso dilation which is widening of the blood vessels. Then we have vasospas spasm which is constriction or narrowing of blood vessels. We have atri or atrio which is relating to the atria of the heart. For example that could be atrial which is pertains to the atria. Atrio ventricular which pertains to the atria and ventricles. Atrio ventricular node which is a node of specialized tissue in the heart that conducts electrical impulses from the atria to the ventricles. Then we have ventricular or ventriculo which relates to the ventricles of the heart. For example, it could be the ventricular which is pertaining to the ventricles. It could be um ventricular megaly which is enlargement of the ventricles. Ventricular fibrillation. This is a chaotic irregular heartbeat originating in the ventricles and can be very deadly. If you all are not familiar with ventricular fibrillation, um it is uh a very serious condition that if not treated very quickly, it can and in fact kill a patient. Then we have u my or myo which denates uh denotes the muscle in cardiology. It often refers to the heart muscle. We have the mocardium which is the muscular tissue of the heart. Then we have the myioardial infuction or MI. Some people call it an AMI. It can be called a STEMI or an in STEMI. We'll get into all of those terms further throughout the presentation. But a mocardial infarction is what we call a heart attack. This is where blood flow to a part of the heart is blocked leading to damage or death of the mocardium. Then we have endo. This relates to the in inner layer of the heart. This is in cardiology it's often referred to the inner lining of the heart or blood vessels. For example, endocardium, the inner lining of the heart's chambers. Endocarditis. This is inflammation of the endocardium, which is often caused by infection. And then the last one that we're going to cover for this slide is perry. This is denoting around or surrounding. For example, this could be the paricardium. That's the sac that surrounds the heart. The uh then we have paricarditis. This is inflammation of the paricardium. And these prefixes are crucial to understanding and describing various conditions and structures within the field of cardiology. It is very important for us to know our anatomy and physiology to properly code within the cardiology specialty. So then we're going to get into coronary arteries and bypass graphs. Now um in today's presentation we will not be diving into cabbage but I did want to include this visual. I feel like it's a very good uh visual of the heart. It shows um here we have the vein graph to the first diagonal branch of the L or the left anterior descending uh artery. Then you have the vein graft to the right coronary artery. You have the vein graft to the posterior descending artery which is also considered the posterior side of the heart. Then you have the left external memory artery which uh is what they use for the L artery. Uh here is three vein grafts to the first, second and third obtuse marginal branches. So if we were to cover bypass graphs of the heart and we would be coding those out, um this is what you would see if you were looking at a patient's heart if they were doing vein grafts. What they're doing is is by definition of the term they are bypassing one area of the heart to redirect the blood flow to another area to uh like avoid whether it be that severe stenosis that severe blockage in another area of the heart. So then we have the cardiac electrical conduction pathways. This is another great visual when you are thinking about how the electrical conduction pathways happen within the heart. The purpose of the uh conduction pathways are to coordinate the pumping of the four chambers of the heart and to control the heart rate so that the heart speeds up and slows down as the demands of the body change. As you can see here, if you start at the beginning where you have the superior vennea, then you have your syinoatrial node or more commonly the SA node. You see how it enters through here and then the arrows flow to different areas based on the electrical conduction pathways. So they flow through the right atrium. They flow through the right ventricle. Down here is the inferior vennea which is uh superior is upper, inferior is lower. Then you have your uh perkingi fibers which also play a vital role into the conjunction system. You have your bundle branches which are in the middle of the heart. Here's your left ventricle where your bundle of his lies between your right and your uh left ventricle. Here are your pulmonary veins that we mentioned earlier. There's your left atrium and here is where your um atrio ventricular node or AV node lies. Okay? So, you're going to hear that a lot within cardiology. You're going to hear the SA node or the AV node. Um if you code for EP and ablation procedures, which we will be getting into more later on in today's presentation, you're going to hear about the bundle of H. You're going to hear about the perkingi fibers, but this is a great visual to get you started on how um the electrical system works within the heart. Now, here's another really good visual for ablation anatomy. Okay. So, um, as I stated, we'll be covering that further later on in the presentation, but you will see that if you're billing for EP and ablation procedures, there are different areas where they provide ablations. So, if they're providing an ablation on the left atrial appendage, here is the line for the uh to the left atrial appendage. if they are doing an ablation on the roof line. If you're familiar with uh these procedures, you'll hear that term stated, they'll state near the left atrial appendage or near the roof line. And as you can see here is the roof line. And if you think about it like a house, obviously the roof is at the top. If they are doing a PVI ablation or a pulmonary vein isolation procedure, there is going to be what we call the box lesion set. And as you can see, here's your left pulmonary vein. Okay? Then you have your right pulmonary vein. And then they also will um isolate all four areas. And that's how they create that pulmonary vein isolation. There are other types including uh they may do the Marshall ablation which is um a lesser procedure but still is done. Uh down here you see there's the coronary sinus which is where they'll be placing the catheter. You'll hear that in ablation or you'll read that in ablation procedures when they place it in the coronary sinus. Now sometimes when patients have uh atrial flutter uh they will ablate the cavo triricuspous ismas line or the endocardial which is right here. You'll see that a lot with a flutter. Um um like I mentioned a minute ago with the right pulmonary vein isolation which is right here. Okay. They may also do a line from the uh SVC to the IVC which we mentioned a minute ago. This is your superior vennea and your inferior vennea. Okay. Uh remember that with ablation procedures there are multiple conditions that they could be treating depending on the type of ablation that they're doing. They also could be doing just a super superior vennea circumferential lesion ablation which would occur right here as you can see where the arrow is pointing to. And then as we mentioned earlier, we have the uh roof and the floor lines, which when I mentioned earlier, a box set completion for the ablation. That's what they're talking about. They're talking about the left pulmonary vein, the right pulmonary vein, the roof, and the floor lines. And that, as you can see on this visual, makes what we call a box set. So now we're going to be looking at dualchamber uh or by ventricular pacemakers. So if you are familiar to cardiology coding and you bill for uh pacemakers or uh cardiac defibrillators, you know that there are three different types of leads that can be placed within the heart. So uh we have in red as you can see the red line here is the right ventricular lead that can be placed. So it's going to come down through the superior vennea. They're going to thread it in and it's going to sit uh somewhere in the right ventricle. And as you can see by the right red lead here, it sits right here in the right ventricle. Then there is an additional lead that can be placed. Now uh there are uh three different code sets for pacemakers that we will also be covering later in the presentation. But they can place a right ventricular lead on its own which is a single lead pacemaker for the RV. Then they can do a single lead for the right atrial lead only which is this uh green line that they thread through the superior vennea and then it stays in the right atrium. You see the placement here is directly in the right atrium. Now uh they can also do what we call a dual chamber or dual lead pacemaker or ICD where they're placing both the right ventricular lead and they're placing the right atrial lead. That's called a dual chamber and that can be done for both a pacemaker or a cardiac defibrill. Now, in some cases, there are patients that require a third lead, and that's going to be your left ventricular lead, and it's going to be this blue color. So, as you can see, it uh is threaded through the superior vennea just like the other two, but it's going to end right here into the left atrium or sorry, left ventricle. So it's pulled through the right atrium and then it ends up being in the uh left ventricle. Now um typically you are not ever going to see a pacemaker done or a ICD done with a left ventricular lead only. Um you are going to see either a single chamber which is going to be the RV or the RA lead. And then if they need to do an additional lead, they'll do the left vent ventricular lead. Now there are times where they'll do a dual chamber, but in instead of being right ventricular and right atrial lead, it will be a right ventricular and a left ventricular or a right atrial and a left ventricular. Okay? But remember that those are coded differently and we will get into that more later on in the presentation. But ultimately this visual is more just so you can see where they place the leads for a pacemaker or a cardiac defibrill. Now just another note to notate here. This is the pacemaker unit which has the battery in it. And this is usually placed right below the skin in what we call a pocket subcutaneously or uh more in depth below the skin and that's what actually functions as the um the system that works these leads within the heart. Now a pacemaker works a little bit differently than an ICD and we will uh also discuss that later on in the presentation. So this next visual is a personal visual that I use when coding cardiology. Now uh for those of you that are attending you will receive a copy of the slides but if you would like to have a copy of this um on its own in the full form uh I would be glad to share that with you. um as well. So this is something that I uh started using like 8 years ago and uh you color code based on where the location is when you are doing interventions. So these are modifiers that you use when you are coding for what we call um perccutaneous interventions or um when they're putting a stent in the heart. So when you are billing for uh stints you have to use the appropriate artery modifier. So as you can see here in orange is your left anterior descending artery. So any done in the left anterior descending is colored orange. So if they do a stent in the main artery for the left anterior descending, it would be through this main area here. If they did it in a branch, you have the D1, which is the first branch off the left anterior, and then you have the D2, which is the second branch that they may uh intervene on in the left anterior descending artery. And I have the uh color coding also done on the right side of this page which shows you the diagonal one and the diagonal two for the left anterior descending artery. Then you have your right coronary artery. So everything highlighted in blue is your right coronary artery. Okay. So the main area is the the main artery but then you have uh branches off the uh right coronary. So you have your um marginal branch and then you also have your uh sinus node branch which is up here. I'm going to be honest, the sinus node branch is normally never intervened on, but it is still a branch of the right coronary artery. And then you have your uh posterior descending artery, which is a more common branch that might be um intervened on. You also have your posterior descending artery. Um, so just remember that any of the branches off of any of the main arteries can be intervened, but some are more commonly done than others. Okay. Now, we have our left circumlex, which is our yellow artery. So that's everything in yellow here is our left circumflex. So as you can see it also has branches that come off of it. So your CX of course is your circumflex artery. Then you have your OM1 and your OM2. So this is your obtuse marginal which is a branch and then you have your OM2 which is your obtuse marginal uh second branch and there is the posterior lateral branch here. Okay. So those can also be intervened on. Typically you'll see the OM1 or the OM2 but you can also see the posterior lateral branch intervened on as well. Now the ramis intermedius is a artery which is funny enough not in everyone. Not every person's heart has a ramis intermediious artery. Now it is in this um lavender purple color here. Some people have it, some people do not. Um so it's not commonly intervened because only a percentage of people actually have the ramis intermedi. It is intervened on in some uh instances for people that do have it. It's just less it's a lesser artery. So it's not um it's not intervened uh on near as much as say the right coronary or the left main or the circumlex or the L might be. Now with the left main, so the left main is the darker purple which is right here. It comes directly off the aorta. So the left main um uh does get intervened on. It does not have branches and um although we see um uh myioardial inffections in any of the main branches um some of the most severe the ones that are the most deadly to the patient could be in the left main artery. Okay? Because with the others other than the ramis intermedius, they all have branches that may not be as deadly to the patient as if it was in the left main artery. So you may ask what are the differences between an artery and a vein? So if you look at a lot of anatomy charts, you know that arteries are always in red, veins are always in blue. Okay. So if you come down this visual it shows um moving upward you have the uh adventria you have the blood flow the smooth muscle which is on the inner linings of both the artery and the muscle. Then you have the valve as you can see here within the vein. We have the internal elastic lamina which is also internally within the artery and the vein. And then we have the endothelium which is at the base of both the artery and the vein. Now, here is another really good visual for how to keep your mind um in order of the difference between the um atria and the ventricles. So, think of atria is entering. Okay? Blood always enters through the heart into the atrium. So, think about the doors opening and you're entering through the doors. The blood enters into the atrium. And just like if it were a building that we were entering, the ventricles, think of those as exiting or out. So, the ventricles are where the blood is vented or let out of the heart. So if you were to open the windows to ventilate your heart, ventricles are where the blood is vented or let out of the heart. I think this is a great visual to keep it right in your mind between the atria or the um atrium and the ventricles. Okay. So now we're going to do more of a deeper dive into um the conditions of the heart. Okay. So here is a really good visual showing you how atherosclerosis builds up in the heart. So what is aosclerosis? Atheroscerosis is a buildup of plaque along the artery walls. So here are your red blood cells that are passing through the arteries and then the yellow with the white specks in them is that buildup of plaque. So when we think of aththeroscerosis or you can be called coronary artery disease. This could also be of the lower extremities and it could be peripheral vascular disease. when it builds up and it builds up more and more and more over time it can cause a blockage. So whether you have to have a stent done for a simple athoscerosis blockage or it uh constricts and blocks the entire heart and you have an AMI or what we call a STEMI or you could have a an in STEMI where it only blocks part of the heart. Um this is a buildup over time. Okay. So here is a healthy artery where the blood vessels are able to free flow through the heart with no issue. This is a small blockage that's probably early on in the patient's history. Um so think of cholesterol. So, uh they may have an increased cholesterol rating as well where they're eating these um fattier foods or um uh other types of fats that are unhealthy for the body and then it just continues to get worse and worse if left untreated. So this can be treated with medications. This can be treated uh with um a balloon angoplasty. It can be treated with a um stent whether that be a PCI or a bare metal stint or a BMS stent or if absolutely necessary when a STEMI or a in STEMI occurs. Um, this could also mean that uh they're having to uh remove a complete blockage or open that artery to allow any blood flow whatsoever, which as you know with a complete blockage with a STEMI, it can and will kill the patient without immediate intervention. So let's look a little further into chronic eskeemic heart disease or what we typically would call coronary artery disease. Okay. So now we're really starting to look into our books. If you have your book and you want to open it up, you can reference that as well. Otherwise, let's get into it. So ICD10 CM classifies chronic eskeemic heart disease by the type of disease. Is it athoscerotic? Is it an aneurysm or other types? And then it also talks about what type of vessel is affected. So with I25.1, this is going to be what we would consider the most common um of chronic eskeemic heart disease which is our coronary artery disease. This is I2510 which is your mo your complete code isoscerotic heart disease of the native coronary artery. Now there are additional characters that can be added to I25.1 that can include um whether it be unspecified ANGA um stable ANA unstable anga and it all comes down to the provider's documentation of the full picture of what is going on with this patient. Then we have I25.2 which is for an old myocardial infuction. So when you build this diagnosis code out, this is when they are past initial treatment. So initial treatment for a moardial infuction is within the first four weeks. So after the first four weeks, if they are no longer being treated for that moardial infuction, it is now a history of or what we call a old myocardial inffection. That means it's no longer causing the patient problems, but they do in fact have a history of moardial infuction. So that's when it's most appropriate to bill I25.2. Then we have I25.3, which is when an aneurysm of the heart occurs. So, uh, this can also happen, um, in other areas of the body that we're not going to get into in today's lecture, but there are aneurysms in the brain. There are aneurysms in other parts of the body that can occur aneurysm. Um, so just remember that specifically an aneurysm of the heart is going to be your I25.3. So then we have I25.4, four, which is our coronary artery aneurysm with dissection. So when you see an aneurysm with dissection, this is more serious than just an aneurysm because someone can potentially live with an aneurysm for a long period of time without it causing severe issues. Now, if it gets worse or there's a dissection or it dissects, it opens up, um, then you're going to bill your I254. And this can be a potentially more serious condition for the patient. So we need to make sure that these patients are being followed up on appropriately once an aneurysm is found. Now our next condition is I25.5 eskeemic cardiomyopathy. So you'll see a lot of patients that have eskeemic cardiomyopathy also have congestive heart failure which we will also be covering in today's lecture. But es schemic cardiammyopathy is common but remember that your provider must document it as a schemic cardiomyopathy in order to build this service. There are other types of cardiomyopathy um but specifically I25.5 is for eskeemic. Okay. So, um there's dilated uh cardiomyopathy and some other types that we will be covering. Then there's silent myioardial eskeemia. So, this is I25.6. You see this a lot. Uh providers will document these on uh say a CTA or a MRI MRA of the heart. you'll see that it um they have myocardial eskemia but it's classified as silent meaning without doing further testing it may not have ever been found because it may or may not be causing an issue to the patient. Then we have I25.7. So this is a scerosis of the coronary artery bypass graft. So if you remember earlier in today's presentation we discussed the bypass graphs within the heart and we showed the visual. So once a patient has a cabbage or coronary artery bypass graft done within the heart then I if the athoscerosis um starts within the bypass graft then instead of billing I2510 for regular coronary artery disease you're going to bill I25.7 with the additional appropriate characters as appropriate. um for when the athoscerosis is in the coronary artery byp bypass graft itself meaning in that bypass that the provider uh placed in the heart. Okay. And this can be uh with or without anga. So there are different types of anga like I mentioned earlier. We have unspecified anga, we have stable anga and then we have unstable anga. And that's really going to come down to the provider's documentation and the spec specificity of their documentation. Then we have I25.8 and this basically is a catchall for other forms of chronic eskeemic heart disease. Okay. So uh if you know uh the guidelines for ICD10 coding, you know that other means that your provider gave a uh good documentation of what's going on with the the eskeemic heart disease but with other that means that there's not a more appropriate code that can be chosen. Now with I25.9 chronic eskeemic heart disease unspecified that means our provider did not give us the appropriate documentation to pick a more specified diagnosis. So now let's go into some key documentation requirements. So this is best practice for you to be educating yourself and for your providers to document appropriately. So for chronic eskeemic heart disease, it's going to need the type of affected coronary artery like we mentioned earlier. Which coronary artery? Is it a cabbage graft? Is it with anga or without anga? If it's with anga, what type of anga is it? Like I mentioned previously, if they don't tell us what type, then we would use unspecified. If it is stable anga, then you would use the appropriate additional digits for stable anga which is normally ending in 18. Or if you have unstable anga then you would use uh 1 o is the ending two characters and you can look at that in your book if you're following along. We also want to know the calcification. Is it lipid rich when applicable? We want to know how uh if they've done a cath or they've done a stint uh or any other type of CTA uh MRI, MRA um diagnostic studies, how blocked is this artery? They'll normally give you a percentage of stenosis so the provider knows whether it needs to be intervened on because typically anything below a 70% blockage they're probably not going to do an intervention on. So if you're seeing a 50% blockage in a coronary artery they're probably not going to intervene on that coronary artery. So now we're going to talk about congestive heart failure. So by definition, this is the heart pumping action that becomes less effective over time. It's a reduction in blood supply to the body. So the systemic or uh systematic effects vary depend vary depending on which side of the heart is failing. So with heart failure, this is primarily ventricular dysfunction. Remember we talked earlier about the atria or the atrium and the ventricles. So with heart failure, it typically affects the ventricles. So with the right ventricle, it could that's when they're receiving deoxxygenated blood, it pumps it into the pulmonary circulation for oxygen. the left ventricle that's where it receives oxygenated blood and pumps it uh into systemic circulation. So the two main types we have systolic dysfunction or if you've seen it documented or uh read it in your book that is systolic heart failure. Then we have diastolic dysfunction or diastolic heart failure. So when we are talking about diastolic and systolic um in the human heart. So we have a visual here as you can see with diastol or systol or cy some people say um it's diastol is the filling of so you see it's coming through and then uh cy is the pumping out. Okay. So, uh with cy it is the contraction of the heart chamber and diastol uh is the relaxation of the heart chamber. So when we are talking about systolic heart failure there's a few things that we need to consider. So your code for systolic heart failure is I50.2 two, systolic congestive heart failure. Now, if you know your guidelines, you're already a cardiology coder or now that you are if you're currently learning cardiology, heart failure with reduced ejection fraction or abbreviated as HF lowercase R EF. So, that stands for heart failure with reduced ejection fraction. You may see that your providers document it simply as HFR EF and that is enough information for you to adequately document or for you to adequately code this as systolic congestive heart failure. Now, if they do not tell you the type, then HF EF on its own with no additional documentation codes to unspecified because they're not telling you if it's acute chronic or acute on chronic. Okay. This could also be documented as systolic left ventricular heart failure. That is also coded to unspecified uh uh unspecified systolic congestive heart failure or I50.20 when it occurs when it is documented appropriately. There is a code also note for endstage heart failure if applicable. So that means that you will also code I50.84 when endstage heart failure is also documented. Now remember I said earlier uh the importance of knowing your excludes one and your excludes two notes excludes one. It says combine systolic congestive and diastolic congestive heart failure. That means that if your provider documents it as combined systolic and diastolic congestive heart failure, you lose the I50.2 and you are going to use I50.4. I50.4 is when it's combined heart failure. You would not code individually for systolic and individually for diastolic. Now let's talk about the individual uh specificities for this code. As we already mentioned I50.20 is unspecified systolic congestive heart failure. I50.21 is acute systolic congestive heart failure. I50.22 is chronic systolic congestive heart failure. And I50.23 23 is acute on chronic systolic congestive heart failure. So now let's talk a little bit more about diastolic heart failure. So your code for this is going to be your I50.3. So diastolic dysfunction is the when the ventricles do not fill completely. your ejection fraction is normal to slightly increased. So increased would be 55 to 70% on your ejection fraction. Some of the most uh common causes for diastolic heart failure is uncontrolled hypertension, hypertent hypertensive cardiomyopathy and endstage renal disease. Now when a patient has combined systolic and diastolic dysfunction which is our I50.4 code that we mentioned a minute ago that's when the heart has uh issue has both issues. So the ventricles do not pump efficiently and the ventric or the ventricles do not pump or fill completely. So it's you're neither are they pumping or filling 100%. And this is when you have further issues in the heart. So with diastolic CHF or congestive heart failure, it can be documented as diastolic left ventricular heart failure which codes to our unspecified code I50.30. Heart failure with normal ejection fraction which also codes to unspecified. heart failure with preserved ejection fraction which just like with um our systolic there's an abbreviation and it's HF PF which is heart failure with preserved ejection fraction and simply documenting it as HFP uh codes to the unspecified I5030. This code set also has your code also note for endstage heart failure when applicable for I50.84. You also have your excludes one note which tells you that when you have combined systolic and diastolic CHF, you're going to defer to the I50.4 code section and you're going to lose your I50.3. Now just like with systolic heart failure you have uh now have I50.30 which is your unspecified I50.31 which is your acute I50.32 which is your chronic diastolic and then you have your I50.33 which is your acute on chronic. Now let's take a little bit of a deeper dive into hypertension. So um your hypertension category is from I0000 through I99 conditions. Okay. There are multiple diagnosis codes that fall within the hypertension category. So when you are coding for hypertensive diseases, hypertension should be coded as related with heart disease or heart failure or with kidney disease. And as you can see by the chart here, it gives you tips on how to appropriately code hypertension with other conditions. So hypertension should be coded as related with the heart disease, heart failure or the kidney disease even without proper provider documentation clearly linking them. If you know your guidelines, you know that there is a causual relation between hypertension and congestive heart failure and hypertension and chronic kidney disease. What does causual mean? Causual means that they are associated with or due to by classification. So that means that unless your provider clearly documents that the two conditions are unrelated, they are always going to be linked as if they are related unless told otherwise. Okay? So if your provider documents hypertension by itself, you're going to code I10. If your provider documents hypertension or hypertensive heart failure, you're going to use I1 and I50. Your I50 code is going to be based on your congestive heart failure. So there are multiple codes in the I50 category for congestive heart failure. If your provider documents both hypertension and chronic kidney disease or they document hypertensive chronic kidney disease, you would code from category I12 plus category N18. And there are multiple codes in the N18 category for the different types of chronic kidney disease. Then you have hypertension with heart failure and chronic kidney disease or it may be doc documented as hypertensive heart fail with heart failure and chronic kidney disease. That's going to be from category I13 for your hypertensive hypertension with both conditions. and you will also bill your I50 code and your N18 code. There are also other hypertensive conditions that you can bill. There is hypertensive cerebrovascular disease which requires hypertension code between I10 and I-15. You have hypertensive retinopathy which requires a hypertensive code also for the I10 through I-15. We have secondary hypertens hypertension which means it's due to an underlying condition. Anytime you see due to an underlying condition, the underlying condition uh should also be coded. Um typically with um underlying conditions it would be coded primary to the secondary hypertension and it should have a code first note in your book. We also have transient hypertension. We have hypertensive crisis. We actually have hypertensive emergency uh urgency and crisis but they also require a hypertensive code also note from the I10 to I15 category. And then lastly we also have pulmonary hypertension which is hypertension uh basically the the blood pressure is too high or too low in the pulmonary system. Okay. Or pulmonary meaning lungs. Okay. So now we're going to look at myocardial infuctions. So with a moardial infuction or a MI you have I21.02. So this is a STEMI or ST elevation myioardial infarction involving the left anterior descending coronary artery. If you remember the visual I showed you earlier, the left anterior descending or the L is one of the main coronary arteries. Okay? So, you're going to use your category I21 for your acute MI when it is equal to or less than four weeks old. Remember earlier we were talking about the 4-week point and if it's no longer being treated after 4 weeks or 28 days, then it's considered an old myioardial inffection. Just remember, we do not need to be continually treating it. If they have other issues, the other issues are then being treated with the old mocardial infuction. Uh again, that's our I25.2. But then we have a subsequent ST elevation or STEMI. This can either be a STEMI or a non- STEMI. Remember that a non- STEMI means that it is not a complete blockage. with a STEMI that is a typically a complete blockage and more serious than an in STEMI. If they have a STEMI and then during the same stay they have a subsequent STEMI or during that same 4-week period it's considered subsequent. So you're going to bill your I21 code and your I22 code for the subsequent um either STEMI or in STEMI. Okay. So this is for a type one or unspecified only. For myocardial inffection types 2 through 5, you're going to see the subcategory I21.A. This is a newer subcategory classification that was just put into place a few years ago, but if you're following in your book, you'll see that I21. A is for the different uh types 2 through 5 with I21B. This is a myioardial inffection with coronary microvascular dysfunction. This is not as commonly seen, but it is an option if it is documented as with microvascular dysfunction, and that's going to be your I21 point B. So then we have what we use as our unspecified EMI codes. So if your provider only documents this as an AMI or just an MI, if they are not giving you that it is an ST elevation or they're not giving you um the location of it, you're going to use I21.9 for a unspecified acute MI. when your provider documents it is simply a STEMI and they don't give you the site or they only say that it's a type one STEMI or a transmural STEMI or trans transmural MI and they don't documentate document the site then you're going to use I21.3 both of which are unspecified to the location of the blockage So here are some of our key documentation requirements and I put this good visual over here on the right side of the screen to give you a little bit better understanding of the different types of MIS. So when we are talking about what should be required for a myioardial inffection. So the type so the MI classification from uh third universal definition of MI type one is what we call a spontaneous MI related to plaque erosion and or rupture fissuring uh or dissection. Okay. So here is your plaque rupture with thrombus. Okay. Type two, it is a MI due to eskeeia results from increased oxygen demand or decreased supply. So this could be a coronary artery spasm, a coronary embolism, anemia, different types of arrhythmias, high or low blood pressure. So that's what this looks like. You see this? We talked earlier about what a vasospasm is. Okay. Now, type three is an MI due to sudden cardiac death when no biomarkers are found in the blood. So, basically that part of the artery is dying and they could not find out why. Okay. And then we have type four. Now, type four has three different subcategories. Type four has type 4A which is an EMI that is related to perccutaneous uh coronary intervention. So this means that they've already done a PCI or a stent and the MI is related to an issue with that intervention. Type 4B is an MI related to a stent thrombus. So that means that it actually thrombos within that artery. Then we have type 4C which is an MI related to restenosis. So if you already code cardiology uh you'll hear the term reenosis. So that means that it has already been intervened on previously and it has uh rebuilt up stenosis within the area that was originally intervened on. So remember that your providers also need to document the affected coronary artery. They need to tell us was this initial or was this a subsequent MI? the timing of the administration. Um, so if they're doing TPA, which we're going to be talking about more here in just a few minutes, um, you can bill a specific diagnosis code if the TPA was done at an outside facility. Then also we also want to know if this patient is a tobacco user, their dependent or have they been exposed to tobacco smoke, whether that be in a household or um you know some other area. So like I mentioned a second ago about TPA. So what is TPA? TPA is tissue plasmo plasminogen activator or TPA. This is used for treatment of myocardial infuctions. So if it is documented appropriately, what does appropriately mean? Meaning if they had TPA administered in a different facility in the last 24 hours prior to prior to the admission to the current facility they are being treated at then you can use Zcode Z92.82 for status post administration of TPA. This code is assigned as a secondaryon diagnosis. You would not use this as a primary diagnosis. This is when a patient is received from a transfer transfer from another facility. Documentation must indicate that the patient received TPA within the last 24 hours prior to the admission to the current facility that they are located at. Okay. So now we're going to get into heart blocks and conduction disorders. So earlier in today's presentation, we talked about the cardiac conduction system and where the location of these areas are within the heart. Here is another visual just showing you um the different areas. We we already talked about the perkingi fibers, the bundle branches and we even talked about the bundle of hiss. There are different types of heart blocks that we are now going to cover. So you have a firstderee art block. You have two different types of secondderee art blocks. You have a Mobitz type one and you have a Mobitz type two. And then we also have a thirdderee block or is also considered complete art block. There are four main types of arhythmias. So when we're talking about arrhythmias, we have what we call premature beats. So, when you see premature beats, typically they're going to call them premature atrial contractions or PAC's or premature ventricular contra contractions or PVC's. A lot of times you'll see these on um uh device readings if a patient has um a pacemaker ICD if they've had a halter placed a halter monitor placed um to see what's going on with the patient to see if they need to be evaluated for further issues related to arhythmias. And then we have supra ventricular arhythmias. So these include atrial fibrillation or AIB, atrial flutter, peroxismal supra ventricular tacocardia abbreviated as PSVT and we also have Wolf Parkinson wipe syndrome or WPW. So a couple more arhythmias that we want to cover today is ventricular arhythmias which are ventricular tacocardia and ventricular fibrillation. If you remember we talked about ventricular fibrillation um a little bit at the beginning I told you that this was a chaos within the heart and this can be very fatal if not treated uh immediately or as soon as possible. Okay. Typically with ventricular fibrillation, uh you see that the patient uh goes into cardiac arrest and uh has to have CPR done or um have a uh elective uh cardio version done or a cardio version in general that can be uh physically done or it can be done by a chemical basis. We also have brady arhythmias to include uh brady cardia. So here's a couple good visuals for strokes or what we call cerebrovascular accidents or abbreviated as CVAs. That's what most people see um uh is the abbreviation which is a CVA. But it's good to know what that stands for, which is a cerebrovascular accident. It's also known as a stroke. It happens to be the fifth leading cause of death in the United States. And the typical causes include thrombosis, imbolis or hemorrhage. So the two main types of strokes are hemorrhagic or eskeemic strokes. So as you see in our first visual here, you see the red. Okay, this is a hemorrhage where blood leaks into brain tissue. So instead of staying in its normal pathways, it's actually seeping out into the brain in areas that it should not be. Then we have eskeemic strokes which seem to be the most common uh where a clot stops blood supply to a specific area of the brain and as you can see here it basically cuts it off. It prevents blood flow to a specific area of the bl of the brain. So, a little bit more about the pathophysiology of a of a CVA or cerebrovascular accident. Again, we have two visuals here just to give you a little bit more uh insight to what it looks like in the brain. So, this could be due to a blood flow interruption in the brain. It can cause brain tissue death especially in an eskeemic stroke because blood flow is no longer happening. So it's killing basically it's killing that section of the brain that's affected. As I mentioned previously the two main types is es schemic and hemorrhagic and with transient eskeemic attacks TAS this is what we call a mini stroke. So a TIA is still a stroke but it may not affect the brain in the same way. Most people recover very quickly from many stroke. doesn't necessarily require any hospital or provider intervention. People can have many strokes for long periods of time uh without being treated because they may not know that that's what's happening without being uh consistently followed by a provider. This could be a a m like a minor zone out. Uh this could cause um eyes to be watering or other um slight variances that you may not notice if you're not looking for them. So this could be a brief interruption of the blood flow to the brain and then it keeps going. So if everything's fine and then typically it doesn't cause permanent brain damage. whereas a uh a full regular stroke um definitely causes brain damage. So talking a little bit more about eskeemic CVAs. So these are specific to the I63 category within your book. So I63 is for cerebral infuctions. This includes occlusion and stenosis of the cerebral or pre-erebral arteries. This results in um cerebral infuction. There is a use additional code if applicable. So this identifies whether they are status postpioned earlier. You would use your Zcode Z92.82 82 after or secondary to your I63 code. It also has use additional if known for the NIHSS score. That's the National Institutes of Health Stroke scale score and that would be coded to R29.7 with an additional character based on the documentation of the provider of the of the score this patient has. We have an excludes one note that states that you can never code neonatal cerebral infuction which is code P91.8. 82 with the additional digits with I63 because neonatal is for uh babies and children, small children uh not for adults. So your PE codes are always going to be for neonates. They are never going to be for an adult patient. Then you have excludes 2, which is chronic without residual effects. So this is what we call a squ a squella or late effects. So when there are no residual deficits to the patients uh health after a cerebral infuction. So if they're currently having a cerebral infuction and you're coding it to I63, but they also had an old cerebral infuction that no that no longer causes causes them any issues. You can also use Z86.73 when there are no late effects from that previous uh CVA. Now if they are having a current CVA and you're coding I63 but they also have a squella of a cerebral infuction that previously happened then you can code I69.3 for a cerebral infuction with late effects and it depends on the late effect to the additional digits used. So a little bit more about our eskeemic CVAS. So I 60 uh 3.0 this is cerebral infuction due to thrombosis of pre- cerebral arteries. We have a couple different uh areas for this. So I63.00 00 is for cerebral infuction due to thrombus of or thrombosis of unspecified pre-erebral artery. This means our provider did not tell us which cerebral artery was affected. I63.01 01 and then you can use the additional sixth character uh based on the ver verte vertebral artery affected. So I63.01 is for a cerebral infarction due to thrombosis of a vertebral artery. So if it's of the right vertebral artery that would be uh your sixth character character one. If it is of the left vertebral artery that would be the sixth character two. Cerebral infarction due to a bilateral vertebral artery would be sixth character three. And then if they are unspecified and your provider did not tell you which one or both you would use the sixth character nine. So cerever vascular instructional notes. So when you are billing these services in the uh category of I60 through I69, you want to make sure that you're using the appropriate additional codes when they apply when they are applicable. Okay? So if there is alcohol abuse and dependence, you would use code category F10 and then the additional characters as uh dependent on whether it's uh alcohol uh abuse or dependence and the other factors related. There's also exposure to environmental t uh tobacco smoke which is Z77.22. history of tobacco dependence which is Z87.891 891 hypertension which we've previously covered that could go anywhere from I10 to I1A occupational exposure to environmental tobacco smoke uh Z57.31 tobacco dependence that means current dependence they are currently still a tobacco user and they are dependent on it um F17 followed by the appropriate characters depending on if it's uh cigarettes or if it's like chewing tobacco or smoking a pipe or the newest uh uh condition which would be people that use vape tobacco products. And then if your provider does not give you enough information to use tobacco dependence, if they only document tobacco use, then you can use Zcode Z72.0. zero. So a little more about when there is a squella or late effect or deficit from a CVA. So deficits occur after the acute episode of the CVA. So the acute episode of the CVA is while they are currently in the hospital for the current CVA for that encounter of that CVA. Anything past the initial episode or initial encounter while they are still in the hospital is considered um outside of the acute quote unquote episode. Okay. So when we have deficits we can use what we call I69 or combination codes. So these are classified by the type of CVA, the deficit that is occurring within the patient and whether it is dominant versus the non-dominant side. So let's talk a little bit about dominant versus non-dominant. By default, if your provider does not document dominant versus non-dominant, then we have um the default as the right side of the body. That means the non-dominant defaults to the left side of the body. But as we all know, some people are left-handed and some people are um ambidextrious. If your provider does not tell you that they are left-hand dominant, you are going to assume the default side, which is the right side is dominant. Okay. So, we have a couple examples of some types of deficits that could occur. I69.121 is dysphasia following non-traumatic intra cerebral hemorrhage. You also have I69.152 which could be hemoplegia or hemoparesis following non-traumatic intra cerebral hemorrhage affecting the left dominant side. Now this by far is not all-encompassing. This is just a couple examples. There are many other I69 codes that can be used for deficits based on the condition and whether it's dominant or non-dominant. So a couple coding tips for when you are um using these squella codes following a CVA. So the I69 category range is assigned on uh record with other I60 codes. So I 60 through I67 if there is a current cerebrovascular disease and deficits from an old cerebrovascular disease. So you can code both at the same time as long as both are currently occurring. So some of the key documentation requirements you need to know the type of cerebrovascular accident or uh disease. Where is the anatomical sight or laterality? Did it affect the right side, the left side or is it affecting bilaterally both sides of the body body? And are there any squella or deficits or late effects um from the cerebrovascular uh issue. Okay. So, we're going to take a short break for those that are uh attending live and then we will uh move on to uh coding um the procedures. Okay. So, now we're going to start looking at an overview of um common cardiology procedures. So uh we are looking at uh four different types of procedures in today's um session. So our first uh section for procedures that we're going to be looking at is diagnostic. So diagnostic procedures can include in today's presentation but can can be much more widespread than just what we're covering today. Um echoc cardiography. So, we're going to be really drilling into non- congenital echo cardiography. Um, but there are congenital codes for this section as well. We're going to be looking at EKGs. We're also going to be looking at nuclear uh and standard uh stress testing. So, the diagnostic test components. So, if you are new to coding, you're still going through learning it, or you're already a current coder, some people may or may not know this. You may have learned it and then forgot about it, or it's just new. So, let's talk about it a little bit. So, uh, some of our procedure codes have a technical, professional, and a global service. So what that means? What that means is is that some procedure codes are inherently a professional service or inherently a technical service. Meaning there is not a modifier to use because the code by definition includes only that component. Now there are other codes that require a modifier if you're only billing for one of the components. So if you are billing for professional fee services and you do not own the equipment, you are going to be using a modifier 26 which is for the professional component when you are reviewing and interpreting a procedure. If you are the facility and you own the equipment and you are only billing for the technical component of the service. So you are not performing it. You are uh providing the equipment to perform it and in that case uh the modifier TC for the technical component would be appended. Now let's make the assumption that you are coding for a provider that owns the equipment and is reading and interpreting the service. In those cases, you can build a global service. What does the global service mean? It means that you are performing all required components for that service. Okay. So that like I said there are certain uh procedure codes that have each individual component broke out and there are some that you must build the appropriate modifier based on the definition of the code. So we're going to be uh talking about echoc cardiography first. So there are different types of echo cardiography uh procedures. So we have transthoracic echo cardiography or we call this tte procedures. Then we have trans esophageal echocardiography procedures and we call these t procedures. Then we have stress echo cardiography or stress echoes and we have te guidance. These are all different procedures. They are all done for different reasons and they are all done differently. So with transthoracic or t procedures we have two primary codes. we have our 93306 and we have our 9337. So with 93306 this is when all nine required elements are documented and it is done with spectral and color doppler. When you have a 93307 that is when all nine required elements are documented and this is done without spectral and color doppler. So there are nine required elements or structures that must be documented to build a complete TTE procedure. Those include the left atrium, the right atrium, the left ventricle, the right ventricle, the aortic valve, the mitral valve, the tricuspid valve, the aorta, which can include the aortic root, the ascending or descending aorta, and the paricardium. Now, there are four other structures that you may see on an echo report that they can document but aren't required to get a complete code. So, you may also see the pulmonary artery, the pulmonary vein, the pulmonic valve and the inferior vennea. But remember, they are not any of the required nine elements but are good to see if they are there. So the other two components that are required to build a 93306 that is our spectral Doppler which may also be documented as CW or continuous wave Doppler or PW or pulsewave Doppler. And then we have color flow Doppler. This may do be documented as CFD color flow Doppler. Uh CDI for color Doppler imaging CFV for color flow volume. Color Doppler or CD or color flow mapping. Now spectral and color flow Doppler are used for different things but primarily uh what they use them for is to see regurgitation within the different valves. that's within your aortic valve, mital valve, and tricuspid valve. You'll see providers try to argue that if there is a regurgitation finding that the assumption can be made that spectral and color flow was used. As coders, we are not allowed to make that assumption. We need to be querying the provider and having them uh amend the record to include spectral and color Doppler if performed. So with a limited TTE procedure, this is when all nine elements are not documented. So we have one primary code for this and it's 933 08. This is for a limited TTE procedure and like I said with uh less than nine of the required elements and this can be with or without spectral and color doppler because this code does not include spectral and color doppler if they are performed they are docu or they are build separately. So, your add-on codes for limited TTE procedures for your spectral is a 93321 when it is documented as a modality and then 93325 if color Doppler is documented as a modality. Remember that both 93321 and 93325 are add-on codes, which means they require the primary code to be build in order to build them. Some of the other add-on codes that you might see for TTE procedures. This is not exclusive to limited TTE. This can be for uh the complete TTE or limited TTE. So we have a category 3 code 0439T. This is for myocardial contrast profusion echo cardiography. This can be done at rest or with stress and is done for the assessment of myocardial eskemia or viability. If your provider is doing this for any other reason besides myocardial eskeemia or viability, it is not separately billable. Remember they must document it as a modality as well as findings in the report. So examples you may see for findings. The endo uh cardium is not well visualized. However, it appears to be normal regional wall motion with defininity contrast. So definity is a type of contrast. You may also see opticin or lumisin documented all of which are types of contrast. We also have add-on code 93356. This is for myocardial strain imaging. So myioardial strain imaging is a modality. It must be documented and they also must give a finding. It may be documented as global longitude strain or GLS in the finding is typically in the left ventricle. It could also be a finding given in a percentage format. So it may say the GLS uh is 39%. Or it may say the GLS is abnormal or normal. Those are all acceptable findings to bill that code. We also have two different 3D codes. So we have 76376 and 76377. Um, inherently both of these are the same type of procedure. Only one is documented on an independent workstation and the other is not. So this is 3D rendering with interpretation and report on uh or of a CT or computed tomography a uh magnetic resonance imaging or MRI ultrasound or other tomographic modality with image post-processing. So basically they're using 3D to look at a particular area within the echo and they're going to give you a finding. We used 3D and there is a 39% ejection fraction. So they're telling you I used 3D and they're telling you what the finding is from that 3D imaging. And remember, the only difference between 76 and 77 is whether or not your provider documents that it was performed on an independent workstation. So the next set of codes that we're looking at are trans esophageal echoes or TE procedures. So we have three codes for this. And remember that we mentioned earlier that with TTE we have a complete and limited code. With TE procedures we do not. We have a global code. We have a probe placement only code and then we have a interpretation code. So 93312 is what we call the global code. It includes the T-probe placement, the image acquisition, interpretation and report. Meaning all required elements were performed by one provider. Okay. So there isn't a nineelement requirement for this set of codes. It is either limited or complete and it doesn't matter uh whether they document it as such because it's still going to be 93312 if they perform all of the required elements of the procedure. 93313 is when the provider places the T probe only. So sometimes this happens when uh a provider is performing a structural heart intervention procedure and anesthesiology is placing the probe and the surgeon is only reading and interpreting the images. So whatever provider is documented as placing the probe is going to build the 93313 and then whichever provider is doing the read and interpretation of the TEE is going to build the 93314. Okay. So remember we talked about earlier there's global and then there uh can be two uh other portions that can be performed. This is one of those sets where you can build the global code or you can bill the individual components performed. So now we're going to look at the add-on codes and these again are for non- congenital. Um now there are some of these codes we've already covered. I'm not going to repeat them. They're just um add-on codes that can be built with either TTE or TE procedures. So with TE procedures, if it is documented as complete spectral Doppler, they can bill 93320. If either they do not document complete or limited or they document it as limited, you bill 93321. We've already covered 93325. And there is no distinction between complete or limited with color flow Doppler. Now there are uh there are a change there is a change between TTE and TEE as far as congenital versus non congenital. So if you are billing a congenital TTE you can bill 3D imaging during the procedure with 93319. Well, you can also bill add-on code 93319 with non congenital TE procedures. And if you have your CPT book and you would like to look that up, you can see that it specifically tells you that it can be built for congenital anomalies or TE nonenital procedures. One thing I would like to advise on is that you cannot bill 93325 and 93319 together. There is a procedure to procedure edit in place. And for those of you that may not be familiar with procedure procedure edits, that means there's a column one and column 2 code unbundling edit that says these two codes can't be built together. And when you have an unbundling edit that way, you have to bill the uh the column one code. So in this case, the 93319 would be appropriate, but we would not build the 93325. Now, we also covered uh the 76376 and 76377. So I'm not going to go over those again, but I do want to make a distinction that 93319 is during the echo procedure for 3D 76376 and 76377 is what we call post-processing, meaning it was done after the initial part of the procedure. So just make sure you know that distinction if you're billing these procedures. So this is just a quick visual of what it looks like when they are performing a TEE procedure. So as you see, we have the provider's hand here. This is the TEE probe. You see it? It looks kind of scary, but don't be scared even if you've ever had one of these done. It is just a probe they uh place through the mouth into the esophagus and down the esophagus. they place it near the heart and it is used for the TEE procedure. So, this just gives you a little bit of a better uh visual to what it looks like when they're performing this procedure. And then our two diagrams up above here is what the provider's looking at in the echo cardiography procedure. Now, a lot of times what they're looking at is whether or not someone has a congenital anomaly. It could be regurgitation. It could be stenosis. Um there are many things they're looking at. They can also determine the ejection fraction on echo cardiography procedures. So the there's a lot of different things they could be looking for for these procedures. So the next code section that we're going to be covering is stress echoes or stress echo cardiography procedures. So there are two main codes for uh stress echoes. You have 93350 and you have 93351. Now when you are billing 93350, this is the interpretation of the stress echo imaging and you can also bill the portions of the stress test performed. So if your provider is doing the supervision of the stress EKG portion and it is documented appropriately, you can build the 93350 with 9316. Now this set of codes is one of those sets of codes I was talking about earlier. That is the professional component and technical component codes. So you're not going to be billing a 26 or a TC modifier on these. they tell you the portion that is completed. So a 93016 is the supervision, 93018 is the interpretation and 93017 is the technical component. So depending on the portion that your provider performed is the code that you bill. Okay. Now 93351 is typically buil in an office setting but can be built in a a facility setting if documented appropriately. So this is what we consider an all-inclusive procedure code. So this is interpretation of the stress echo imaging with supervision and interpretation of the stress test. So that's including your code 93016 and 93018. So you're not billing that separately. But remember, they also have to have the technical component. Okay? So if if your provider is only billing the professional component in a facility, you're going to use the modifier 26 to identify the professional component on 93351. If your provider is performing this and they own the equipment and they're performing all the other components, they can bill this as a global code with no modifier. And then of course, if they were billing for the technical only component, they would only be billing the portions of the technical component build. But remember that it requires the specific amount of all three of the individual components. If supervision is not documented, you would bill the 93351 under the interpreting provider. Okay. So, uh there's a level of of assumption that if they're billing for all the components or the global fee that that that the provider that interpreted also supervised. When you are billing these as component codes, the 93601 or 93016, 018, and 017, they must document the portion that was completed. So, let's talk about a few coding tips for these add-on codes. So, if you're billing in the office, you can bill Q957 when contrast is used. We would not be billing drug codes in the facility setting because the facility would be billing those codes. When you are billing the professional component in a facility where you do not own the equipment, you did not buy that drug. Your provider did not purchase the drug in a facility and therefore they cannot bill for a drug that they did not purchase. With 93351, it can be build in the facility or office setting when supervision is documented. I mentioned that on the previous slide. So, we've already covered the add-on codes for the other procedures, but as you can see, you can bill the 93320, 21, and 25. The only add-on code that differs for stress echoes that you don't bill for the other echo cardiography procedures is 93352. 93352 is when there is contrast used during a stress echo procedure. And that can be in the form of defininity, opticin or lumisonin as we previously discussed um for the category 3 code. So the last um code selection for um our echo cardiography procedures that we're going to be covering in today's session is 93355. So this is for structural interventions. So remember earlier I was telling you that sometimes more than one provider is included in some uh cardiac surgical procedures. So in cases like a TAVER which is a transthoracic aortic uh valve replacement there will be two providers in the O there's going to be a interventional cardiologist and there's going to be a cardiovascular thoracic surgeon. So typically what would be done is the interventional cardiologist is going to be the one that's going to be doing the TE guidance. They're going to be the one that's billing the 93355 and then the structural interventional uh provider, the CVT provider will be doing the surgical portion. There's one very important thing you need to know about this code. The structural intervention provider cannot bill the 93355. If they are billing for the surgical codes, they cannot bill for the TE guidance. It is for the second provider in the room at the time this is done. So there are other um procedures where maybe the anesthesiologist is providing the TEE probe guidance and then the uh provider billing the surgery is doing the rest of the procedure. So it depends on how it's documented to how it's build. But just remember that whoever is doing the surgical portion cannot bill this code. So now we're going to start looking at EKG coding. Again, I would like to reiterate what I discussed earlier where there are certain codes that have a global service, a technical component, and a professional component. and you do not use a modifier 26 or a modifier TC. This is a code section that uses that um guidance. So 9300 0 is the global ser service. This includes the electroc cardiogram, the ECG with 12 leads and interpretation report. That means that your provider performed all of the required components to build a global service which also means they own the equipment. Okay. Then we have 93005. So this code is the technical component. So if all the say the facility is billing is for the tracing which is that long uh piece of paper that shows the EKG uh movement in the heart. So this is the tracing or technical component only. So, if you are the professional provider or you're billing for the professional fee component, you would not be billing the 930005 because that's for whoever owns the equipment. Then we have the 9310. This is professional component only. This is when your provider is only doing the interpretation and report. Okay? They don't own the equipment and they're not billing for the tracing. They're only billing for reading and interpreting that procedure. Next up, we have stress test. Now, we already talked about these a little bit when we were talking about stress echoes. So, stress tests on their own can be done in two different forms. It can be done by chemical form where they inject you with a drug that raises your heart rate and puts you in a stress um sense of uh of um to raise your heart rate. So it's chemically raising your heart rate. Whereas the traditional form of stress test is done on a treadmill or on a bike and you are physically raising your heart rate by uh doing that exercise. So for patients that are in worse health or unable to do the treadmill or back test, they give them a drug such as Lexi scan to chemically raise their heart rate without exercise. Okay. So in this case we have a very similar um situation as that we do with um your EKGs. You have a global code, you have a supervision code, and then you have the professional and the technical components. So, you don't use modifiers on these codes. Each individual code it uh resembles or it accounts for a specific portion of the test. So, 93015 is your global service. That means that your provider documented that they performed the components of the 93016 017 and 01 018 in a nonf facility setting. Okay. So the reason why we don't perform 93015 in a facility setting is because the provider does not own the equipment. If there ever is a situation where your provider does own the equipment in a facility setting, you could bill it. But that is not typical. We have the 93016 which is the supervision of the stress test and this is only the supervision component. Then we have our 93017 which again is just the technical component or the tracing. The 93018 is your interpretation and report only. So your provider if they didn't supervise it or they are not billing for the technical comportion uh they'll bill the 93018. There are situations where provider practices will have one provider supervise and one provider interpret. And in that case as long as it's documented as to who supervised and who read it, you can build the 93016 to who supervised and the 93018 to who interpreted it. So the the next portion of this is going to be the spec or myocardial profusion imaging. So sometimes stress tests are done on their own and that's when you're going to build the 015, 016, 017 or 018. But when a spec test is done or a spectral test is done in addition to the stress test, a lot of people call this the nuclear portion. If you're already building this or you're learning it, this is the nuclear imaging with stress testing. Okay. So our code for this is going to be our 78452. So with 78452 um multiple studies can be done. This can be done at either rest or under stress and they inject a second injection. So if they're doing a chemical stress test and they do a lexi scan that's a particular drug. Now with a nuclear it's a different drug. So it could be a rad nuclide uh that's given again and this redistributes throughout the rest or stress phase and they'll give it to it give it to the patient prior to it or when they're resting from it from the stress test. Okay? And they'll take images at at rest and or stress. These codes also include the attenuation correction or AC. This provides a more accurate diagnostic image for diagnosing defects or infarcted areas by raising the importance of radioactivity distribution that that arises in certain areas of the heart. For instance, it can count from the anterior wall. it accounts for when the anterior wall may be reduced or impeded by the presence of the breast. So, you know, breast tissue um can actually block some of the view during a nuclear stress test. So, what it does is is it allows for them to see that area better under the breast tissue. Also these codes include a qualitative and a quantitative wall motion uh where they can see the ejection fraction under the first pass or the gated technique. So uh there is a lot that can be seen by the nuc nuclear imaging with stress testing. So that's why a lot of times you see these build together. Typically, you see the 78452 with the 93015, 016, 017, or 018 because they're doing the stress test, but they're also doing the nuclear imaging. So, here's a really good visual of what you would be looking at if you were the provider. So, on the left side of the screen, you see the stress image. In the middle is the moardial profusion spec imaging and then they have the rest imaging. So down at the bottom it has the stress spec or the CCTA fused imaging. So this is showing different areas of the heart and they're going to read and interpret this and decide what's going on with this patient. So our next section of procedures is is going to be our cath and our interventional procedures. So, we'll be covering CAT procedures, PCI, and types for both provider and outpatient billing, add-on procedures and modifiers that we bill for these procedures, as well as moderate sedation. First up, we're going to be talking about the right heart cath without coronary angography. So when we're talking about this um one of the tips I want to give is that the right heart hemodynamics must be documented. What is that? Well, what that means is is that this is the right atrial pressure, the pulmonary artery pressures and the cardiac output. So what is a right heart cath? So code 93451 if you're following in your book um is includes the measurements of your oxygen saturation and cardiac output when performed. The cal uh cath includes the right side of the heart and uh the other codes in this area are going to be 93453, 93456 through 93457, 93460 through 93461. So let's talk about what they're doing when they're performing a right heart cath. So the physician is going to thread a catheter through the heart. most commonly through introducing a sheath that is placed perccutaneously into the femoral vein. Now the physician may elect to use a different one. They may use the subclavian, the internal jugular or they could use the anti- um anti-cubital vein instead. Those are much less used but there are reasons for that. the patient may have a pre pre-existing issue that is not allowing for them to enter through the femoral vein. The catheter is then threaded through the right atrium. And if you're picturing this, think of those visuals I gave you at the beginning of today's session. So they're going through the right atrium, through the tricuspid valve into the right ventricle. They're going across the pulmonary valve into the pulmonary arteries. They're also getting those pressures that we talked about a minute ago. They're going to use ECG monitoring for the entirety of the procedure, and they're going to be looking at the intracardiac or intravascular pressure readings or recordings, the cardiac output, the oxygen saturation measurements, and then they're going to be looking at the final evaluation of this procedure to see if additional treatment is needed. But remember 93451 is what we call a simple right heart cath. So it's the right side only and it does not include coronary angography. But we will be covering uh more in-depth information on coronary angography in the um next few slides. So when we are talking about um coronary angography without left or right heart catheterization okay this is only the angography. So with code 93454 this is the angography or angographic uh oaphic angog uh sorry angographic findings for one or more coronary arteries. So they're looking for stenosis or no stenosis. Is there an occlusion? Is there thrombus? Is there a what we call a CTO or chronic total occlusion. Now chronic total occlusions are chronic conditions. This is not the same as a STEMI or an in STEMI which is an acute occlusion. a chronic occlusion uh in most cases CTO's are long-term the patients can live and survive and sometimes do have to be have to be intervened on but it is not as serious of an acute issue as a STEMI or an in STEMI would be okay we they're also going to be looking for uh whether there's normal flow that it's patent throughout and uh Timmy flow which comes great into consideration uh when you're talking about chronic total occlusions which we will not be going into great detail on in today's session. Then we have 93455. Now with 93455 this is the angioraphic findings for one or more coronary artery or vein or uh artery bypass graph which we talked about earlier. your cabbages that must be documented. So again they're looking for that stenosis or no stenosis occlusion thrombus CTO is it normal patent and what is the flow look like when angography of the right or left internal memory artery or IMA is performed to determine s uh suitability for use during a future bypass surgery. The appropriate diagnostic cardiac cath with angography code would be in follows 93455 57 59 or 61 to report a total catheterization for all components performed. So our next section of codes that we're talking about is going to be our coronary angography with a left heart cath or catheterization. Now, uh, by far, if you are a cardio coder or you're you're learning this for the first time, um, 93458 has got to be the most build, uh, cardiac cath uh, out of all of the cardiac cath codes. 93458 is what we would consider your traditional left heart cath. So, this is what we see the most of. A 93458 is a left ventricular end diastolic pressure measurement. So that's abbreviated as LV EDP or left ventricular end diastolic pressure measurement. They have to cross the aortic valve in order to get this measurement. It can also include but is not required to have left ventriculography to be documented. Okay, so that's and or not required. So, uh if you need additional clarification, you can always refer to the Cath lab report. So, for those of you that are just learning this, there is always going to be two reports. There's going to be your provers's op report for the for the cath. And then there's going to be the cath lab report that has all the uh details of what happened, what type of catheter they used, the the medications for the moderate sedation, who monitored it, um all the areas that they passed through, that's what's on the cast lab report. So if you ever need further ca uh uh clarification on something that your provider did other than just querying your provider, you can refer back to the cath lab report which is uh always going to be or should always be scanned into the facility chart. Now, we have an add-on code for this, and that's 93462. And this is when a left heart cath is performed by transceptal puncture through an intact septum or transapical puncture. Now, we're going to talk a little bit more about this code once we get into EP and ablations uh at the end of today's presentation, but just know that 93462 is specifically for the transceptal or transapical puncture. Okay? and it's an add-on code, so it must be built with a primary code. Documentation must specify that the left heart was entered via a puncture in the septum or via a puncture in the atrium instead of entering through the aortic valve, which is what's traditional for the 93458 procedure or 93459. If a patient already has an atrial septile defect, that's a congenital anomaly. For those new to this section, an atrial septile defect or an ASD is a congenital anomaly. The septum is not intact and the code would not be reported because you're not having to poke through it. You're not having to puncture it. it already has an opening because it's not closed. With right heart uh hemodynamics, they must be documented such as the right atrial pre uh pressure, pulmonary artery p uh pressures or the cardiac output for the right heart portion that is typically not included with a traditional left heart cath. Now when you build a 93459 that is all of the components that are incorporated in 93458 but they are also looking at graphs. So you would not be building a 93459 for someone that has not had a coronary artery bypass graph done or cabbage as we discussed earlier in the presentation with that great visual. Okay. So if a patient has had a cabbage done, a coronary artery bypass graph, they're going to have graphs that need to be looked at when a cath is done. That could include the internal memory, the free arterial um or other venus graphs that occur only when a cabbage is done. So our next set of codes for our uh cardiac caths this is uh coronary angography with combined left and right heart caization. So this is what we call uh a combo cath. So they're doing everything that's included in a in a traditional right heart cath. They're doing everything that's included for a traditional left heart cath, but they're doing them together in one uh op uh operating room session. Okay. So, for these you have two different codes as well. 93460 is a complete right and heart right and left heart cath that like I said includes all the other elements we've already spoke about for individually left and right only they're doing it all at the same encounter. Your 93461 is when they also have those graphs. So, as we mentioned with your 93459, if a patient has had a cabbage done, they're also going to want to be looking at those cabbage graphs, and that's when it would be appropriate to bill your 93461. So, now we're going to get into our P perccutaneous coronary interventions or PCI procedures. So, sometimes these are called stances. Um, sometimes they can do bare metal stances or BMS stances. Bare metal stances uh kind of went out a few years ago when the PCI procedures got got more popular. So, there are a couple different type of lesions that are done for stint or PCI procedures. So, we have two different codes. We have 92928 which is the first stint placed in any artery or graft. And it doesn't matter how many stances they place in that single artery. You cannot bill 92928 more than once or the same artery. They could put three in there, four in there, and you're still only going to get 92928 one time because it's done per vessel, not per stint. Okay. Then you have 92929 which is when uh a second stint is done within a branch of that artery. So let's take the L for instance. So they put a stint in the main L artery and then they also find a blockage or a higher percentage in the uh first diagonal or the second diagonal branch. you would build 92928 with your LD modifier and then you would build your 92929 with your LD modifier because the diagonals are branches off the L. Now, I want to caution you that if you are a cardiology coder or your training for cardiology, uh, sadly enough, 92929 is going to be deleted in 2026 because payers like Medicare are not wanting to pay for that service because it doesn't have work RVUs or a payment attached. So next year we're having a big overhaul that I'm not going to get into on today's session. Just know it's coming. So the two types of lesions we have continu contiguous lesions which is a single lesion that extends from one target vessel that's a major coronary artery a coronary artery bypass graph or a coron coronary artery branch into the target vessel but can be revascularized with a single intervention bridging two vessels. So, if you ever see your provider saying that that they did a bridging um stint, you can still only get one single code. Even though it went from one vessel to another vessel, it's all uh contiguous, meaning it's it's uh one complete section of that those two arteries, meaning it keeps going. It doesn't space and then pick back up. Then we have what we call treatment of a bifurcation lesion. When a bifurcation lesion lesion lesion is treated, PCI is reported for both vessels because it's happening in two different vessels without being continuous or ongoing. For example, when a bifurcation lesion involves the LD and the first diagonal, it's treated uh stinting both codes 92928 and 929 are reported. But if the bifurcation is in two different main vessels or arteries, say for instance 929 or the LD and the LM for the left main, you would build 92928 LD and 92928 LM for the two different lesions in two different vessels. Okay. Now, if there is a bifurcation lesion in the same artery, so they were both in the LD and you're having to treat that bifurcation lesion, you would be a 92928. If it was only treated, listen, if it was only treated with the the second lesion was only treated with a angoplasty or what we call a PTCA, perccutaneous transuminal coronary angoplasty, PTCA, you would build 92921 instead of 92929. 92921 is also an add-on code that also requires the primary code in order to bill. So our next uh section for perccutaneous coronary interventions. So we have what we call an athererectomy. So an uh in order if you're thinking about uh levels of procedures an angoplasty um is the the basic part of the procedure then you have a stent which is um more intensive than just an angoplasty. Well more intensive than a stent is what we call an athererectomy. So we have two different codes for athererectomies. we have 92933 and we have our add-on code for 92934. So this is called a perccutaneous transuminal coronary atherctomy instead of uh angoplasty which we covered just a minute ago. This includes your angoplasty and your stent. So you would not bill separately for the angoplasty or bill separately for the stint. When you bill for an athererectomy if a stint and or angoplasty is also performed you cannot get separate codes. It is always going to bill as one code 92933 and you would bill your appropriate vessel modifier. So if this happened in the L, you would build your LD modifier LM for your left main, RC, LC or R I if they have a uh ramis intermediious uh artery. Now your add-on code is when um they do a second athererectomy with or without stent and angoplasty in the branch. So, same scenario. They did an atherctomy in the main artery of the LD and they also had to do one in the first or second diagonal branch off the LD. You would build your 92934. Now to my understanding 92934 92934 may also be getting deleted in 2026 as well but for today's session just know that it does still exist and it can be used but may not be paid for specifically by Medicare payers or anyone else that follows Medicare guidelines. So earlier we talked about STEMI or MI for the definition of the diagnosis code. But now we're going to talk about STEMI or MI in the form of CPT code. So if the patient comes in with a STEMI or an MI and they have to have the intervention done. Remember I told you that a STEMI is very um high morbidity or mortality. without intervention, the patient can and very well may die without intervention. So when uh a provider does an EKG or some other type of testing and uh finds a STEMI or an MI, they're going to be taking them to the O directly. There's usually not a m um a carryover time where you know hours or a day or two might pass with an in STEMI. If the patient has a STEMI, usually they're going to be to the O within like three hours of finding it, preferably immediately. So with um 92941, this is specifically for an acute total or subtotal occlusion during a acute moardial inffection or an AMI. This is in a coronary artery or a cabbage graft. And it can be any combination of intracoronary stent, atherctomy and angoplasty. That means the codes that we just covered for our angoplasties, stances and atherctomies, your AMI code is going to win out on on all of those as far as intense. So it goes in order. Angoplasty, stent, atherctomy. But if they are having a STEMI, you don't bill any of those. You bill the 92941. But remember, it has to be within a certain time frame or it's not considered urgent or a true STEMI. So if it's over a certain time period, all you're going to get is the angoplasty stint or atherctomy codes. Now this also includes aspiration throbectomy. We won't be going deep into throbectomies today. That's a presentation for another day. But aspiration throbectomies uh are not build separately. If for some reason the provider did a mechanical throbectomy, there is a separate code for that. Now we mentioned earlier chronic total occlusion. We're going to briefly go over this uh set of codes as well. So a chronic total occlusion, better known as a CTO, can be intervened on. And like I said, this is not an acute condition. This is a chronic condition. This means this patient may have had this a year, 2 years, 5 years or 10 years before it needed to be intervened on. So your two codes is your 92943 and your 92944. 92943 is your primary, your 44 is your add-on. So this is a perccutaneous transuminal revascularization of a chronic total occlusion. Remember I mentioned earlier Timmy flow. Typically with a um chronic total occlusion, your Timmy flow is going to be zero because they're not getting any flow. It's a total occlusion that has been chronically existing within this patient's artery uh branch or cabbage graft. And remember just like with a uh an MI intervention it includes stent athererectomy or angoplasty when performed and again with the add-on code this is for the additional branch if performed and also might be getting deleted in 2026. So some of the add-on codes that uh are typically performed with um angoplasty or PCI procedures. So we have our uh 929 73. So this is when perccutaneous transuminal uh coronary throbectomy with that's mechanical. Remember a minute ago I said that if it was aspiration it's not built separately but if it's mechanical it would be build 92973. If they have a um 92974 for coronary uh uh breaky therapy. This is not commonly done, but if you see it done, you're going to bill it with a 92974. With 92978 and 92979, this is called intravascular ultrasound or optical coherence tomography. Some people call it IVIS, uh some people call it OCT. It really depends on the provider, okay? But it's the same procedure either way. No matter if your provider calls it IVIS or they call it OCT, the primary code is 92978 and the uh add-on code is 92979. What does IVIS or OCT do? So basically they're using an ultrasound device to further look within the vessel. Okay. Then we have our 93571 and our 93572. Now this is also a primary and add-on code. This is called um intravascular Doppler velocity andor uh pressure. Uh more commonly you'll see it as FFR or fractional flow reserve. There are some newer forms of this like coronary flow reserve or CFR or the newest and the most popular is IFR which is instantaneous flow reserve. Now, they're looking at updating this code, but currently a drug must be used in combination to bill this service. If a drug is not used during this service, you have to bill it with a 52 modifier for reduced services when a drug is not used. And then our last item code we're going to be covering today for PCI procedures is our 92972. Now this is for perccutaneous transuminal coronary lithotripsy. So, lithotripsy used to be very popular, still is very popular for people with um um urethal stones, bladder stones, and kidney stones where they use a device to break up that stone so it's easily passed through the urinary tract system. The same goes for lithotripsy of a coronary artery. They go in there with this device to break up that stenosis to make it easier to either suck out with a device or allow it to uh pass without further clotting the artery. So again, I'm only going to just briefly breeze by this particular slide because we went over it earlier in the presentation. the modifiers you're going to use with the codes we just covered for your PCI procedures. Uh LM left main LD L uh LC is your left circumflex. Your RC is your right coronary and your RAR is your ramis intermedi. Make sure you're using your vessel modifiers because some of the insuranceances can and will deny if it's missing them. So uh briefly we are also going to talk about um moderate sedation. Now this is a cardio boot camp but keep in mind that moderate sedation is used with a lot of cardiac procedures because not a lot of the cardiac procedures require a person to go under deep anesthesia that requires an anesthesiologist. Most of the time moderate sedation is performed monitored by the provider and overseen by an RN or another um clinical ancillary staff while the the cardiologist is performing whatever procedure they're doing. Okay. So co so the code for moderate sedation for the professional side of things is 99152. There's also an add-on code 99153, but we don't use that for professional fee coding. If you're billing for the facility, you can bill 99153. 99152 is for the first 15 minutes or the only code we bill for professional fee. And then 9953 is for each additional 15 minutes they can bill a unit. But remember, you're not going to get paid for that in the professional fee. you're only going to get paid if you're billing for the facility. So keep that in mind. So a few coding tips for 99152 for moderate or what we call conscious sedation. So you don't want to report 99152 if the intraervice time is less than 10 minutes. So if they do a calf and they tell you that the moderate sedation was less than 10 minutes, let's say 8 minutes, you can't bill it because it must be at least 10 minutes of intraervice time under moderate sedation. Also, you would not want to report 99152 if the patient is younger than 5 years old. If they are less than 5 years of age, you're going to build 99151. Now with most of the procedures we covered today, these are not going to be in young children. Some congenital con uh procedures like congenital echoes and some of the other things you see in children. But most of the uh chronic conditions we've covered today, you do not see in children. You see those in adult patients. And as I stated, 99153 is the add-on code, but for professional fee coding, we do not get reimbursed for 99153. So, I'm also just going to briefly uh cover this slide only because this is for outpatient surgery PCI codes. If you are billing for the professional fee um side of things, you will never, let me repeat, never use a CC code. Codes are for ambulatory surgical centers, outpatient surgery for the facility and they are never going to be seen in a professional fee billing uh side because we bill for the procedure performed not for the um the devices or drugs used. So in this case, these C codes on this slide are essentially the same thing we're billing when we bill a uh 99 or sorry a 92928 29 uh a 9294143 uh 34. Those codes only their billing from the facility side, not from the provider side. So I'm not going to get into these deeply. These are more just for your information only. So now we're going to get into pacemakers. So uh this in my opinion is one of the best sections um for um simplicity and coding. So, all of these procedures are complicated and I get that, especially for um new people that are training for their CPC or uh coders that are not well-versed in cardiology coding, but pacemakers happen to be one of my favorite things to code. Just my personal opinion. So uh like we mentioned early on in the presentation there are three types of systems. So you have a single, dual and multi-system uh lead device that can be used. Uh to reiterate, we talked about the right ventricular lead, right atrial lead and the left ventricular lead. So right ventricular or right atrial can be single. They can be together and be dual or one or the other can be done with an LV lead which is a left ventricular lead or all three together as a multi-system. So a uh pacemaker is a small electronic device that is implanted to help control abnormal heart rhythms. So as you can see from the visual on the right side of the screen, we have a pacemaker device that in that incorporates the beginning of all the leads and the battery that runs the program itself. And then through the system you see the leads come up and go through the inferior vennea into the heart whether that be the right atrium, right ventricle or the left ventricle which is not pictured on this um visual. So it delivers pacing pulses and it stores data about the arhythmias that are detected and the devices response. Now, a pacemaker works a little bit differently than an a cardiac defibrillator because a cardiac defibrillator is for different diagnosis and actually can cardiovert the patient back into normal rhythm. Okay? And we're going to talk about that in just a second. So, implantable cardiac or cardio uh verter defibrills, this is an for short. So again, just like with a pacemaker, we have single, dual, and multi-systems for depending on how many leads are uh inserted. So just like with a pacemaker, you have the main system here that has the uh battery in it. Then you have the leads that come off of it. They feed it into the heart and they are placed in one of those three areas depending on what is needed. It treats rapid heart rates such as ventricular tacoc cardia or VT or ventricular fibrillation VIB. Uh there are other conditions that this can be used for um to prevent cardiac death um in addition to congestive heart failure, cardiomyopathy and some other conditions. It delivers pacing signals and shocks as needed. But it also does store data and the devices response to that arrhythmia. And both pacemakers and defibrillators have a battery that will eventually become end of life or uh EOL. And end of life means that they're not going to have to replace the whole system. They may just have to go back in and replace the battery once it gets to end of life. So let's talk about the codes. If we are billing for new system implants, a pacemaker has three codes. A defibrillator, one code. Don't ask me why. I had no control over this, but it does blow my mind that we have three for pacemakers and we only have one for defibrillators. So the three main codes for a pacemaker 33206 is a new pacemaker or a replacement pacemaker for only the atrial lead. One lead and only the atrial lead. 33207 is new or replacement pacemaker with only one lead and that one lead is the ventricular lead. 33208 is a new or replacement pacemaker with two leads and those two leads are the atrial and the ventricular leads. We will get to lift ventricular in a few minutes. Now, if you're doing a defibrillator, if they are billing for a defibrill, it does not matter if it is single or dual. And it doesn't matter if it's just the atrial, just the ventricular, or both the atrial and the ventricular leads, you're still only going to bill 33 29. Now when they have to do generator change outs. So this uh does happen sometimes um when uh the the entire system has to be replaced. So when they're doing generator which means that that uh piece that holds the battery and distributes the leads when they have to change out that entire generator. Okay. They're having to take one out and put a whole new one back in. If they were replacing a single lead system, doesn't matter if it's only atrial or only ventricular. If it's one lead, it's 33227. If it is a dual lead system, so atrial and ventricular, you're going to be 33228. With a multile system, which is your atrial, your ventricular, and your left ventricular lead, 33229. Now, we do have multiple codes for defiill change outs. So, if you have a single lead, 33262. If you have a dual lead, 33263. And if you have a multile, it's 33264. So, what are the appropriate diagnosis codes that we bill with pacemakers? Now I'm going to tell you if you are not familiar with cardio billing uh they are very very strict on what is billable for pacemaker diagnosis codes. So I've included the NCD which is a national coverage determination meaning it covers across the country. It is not specific to area. 20.8.3 for cardiac pacemakers. This is for your single and your uh dualchamber pacemakers. Your codes 33206 through 208. And it is very specific. The nationally covered indications include one of two. documented non-reversible symptomatic brada cardia due to sinus node dysfunction or and documented non-reversible symptomatic brada cardia due to secondderee and or thirdderee atrio ventricular block we talked about those earlier secondderee or AV block earlier in today's presentation those are the nationally covered indications that you can bill this for. If it is not a nationally covered indication, you very well may and or will get a denial for these three codes. So, let's talk about our pacemaker modifiers. These are specific to uh pacemakers for cardiology, but like the kx modifier GA and GZ um are used in other areas. uh I also believe that the SC modifier might be used in other areas but we are today only talking about the cardiology specialty. So for cardiology specific pacemaker modifiers the kx modifier is going to be appended when um the appropriate diagnosis code is build meaning the medical policy has been met. The requirements to bill a pacemaker has been met. So, if you bill a 206, a 207, or a 208, and all the requirements have been met, you need to make sure you put your KX modifier on there, or they will deny it because they're going to assume, and they, as the insurance company, are going to assume that that the patient did not meet the required elements of that medical policy. The SC modifier can be appended. Uh typically the SC modifier is appended um for Medicare patients when it is medically necessary. Um SC is typically just Medicare when it when it meets the requirements for medical necessity. Your GA and GZ modifiers are also Medicare modifiers. Um GA is a waiver of liability that is issued based on payer policy. And basically what this is stating is that uh the provider presented an ABN to the patient. They signed it and it is on file that they are aware that um this uh might or might not be paid basically is what that's saying. If for some reason Medicare does not pay for it, they know that they are going to be responsible. A GZ is a WA waiver of liability modifier that is also required per payer policy based on individual case uh specifically stating that they are not responsible for it and they are not asked to sign an ABM form. So those are the different modifiers that can be used. So now let's talk about diagnosis reporting for ICDs. So the ND NCD policy 20.4 for implantable cardiac defibrills or ICDs. This is um policy MM10865. So the NCD states that revision with removal of requirement for the patient to be enrolled in a registry because with ICDs they're in a in a registry that means that it's being tracked under a clinical study for ICDs that were implanted for primary prevention of sudden cardiac death. remember me mentioning earlier that there are other reasons why they would put an ICD uh in and there's either primary prevention for sudden cardiac death or secondary prevention for cardiac death. So effective February 15 uh 2018 there was a coverage policy that is no longer contingent on participation in the trial study or registry. Therefore, claims with a data service on or after February 15th, 2018 no longer require trial related coding. So that means that after that date, it was no longer being tracked. Now, as of March 3rd, 2020, coverage policy updates uh also allow for congestive heart failure to be build for the imple implementation of or the implantation of ICDs. That's very important to note because prior to that it could not be buil. Congestive heart failure and cardiomyopathy are some of the most common uh diagnoses that we use for secondary prevention of su sudden cardiac death for the reason to implant an ICD. So uh our next uh section that we're going to be covering and our last section for today's session are comprehensive EP studies and ablations. So the first two codes that we're covering are comprehensive EP studies. So the only difference between these two codes um is the induction or attempted induction of an arhythmia. So on a rare occasion there will be no attempt to cause a arrhythmia with pacing. This might be due to the patient presenting with an arhythmia. So there's no need to induce an arhythmia. In most cases, an arhythmia is induced as there is a need to find the source of that arrhythmia. So an attempt to induce can be made without success at creating an arhythmia. Whether the attempt to induce was successful or not doesn't matter. If if an attempt was made, code 93620 is reported for a comprehensive study. If there is no attempt made, you you code 93619. That is the major thing to keep in mind with these two codes. But by definition, you have to have the pacing and recording of the electrical pathways in the right ventricle and the right atrium. You need to have recording of an electrical pathway in the bundle of H. All of these activities are described in the two codes that we just talked about. It requires um all of the required EP elements in order to bill the right atrial pacing and recording, right ventricular pacing and recording, his bundle recording, and uh includes the insertion and repositioning of multiple electrode catheters. Like I mentioned earlier, the only difference is is in in 1 N you're not trying to induce or attempt to induce an arhythmia and 20 you do attempt whether it is successful or not to get an induction of an arhythmia. So now we're going to talk about the add-on codes for EP uh studies. So there are two different CPT codes we use for uh pacing and recording in the left atrium and the left ventricle when they are performed at the same time as a comprehensive study. Code 93621 is reported when a catheter is placed in the coronary sinus or left atrium for pacing and recording while 93622 describes pacing and recording in the left ventricle. Pacing and recording from the coronary sinus or left atrium is fairly common while less common from the left ventricle. These codes are both add-on codes and are restricted to be reported in addition to the primary procedure code. There is a parenthetical footnote in the CPT book that tells you this. So to bill 93621, you must bill one of the three following codes. 93620, 93653, or 93654 as appropriate based on documentation. And then for your 93622, it can only be reported with 93620, 93653 or 93656 based on the appropriate documentation and reason for the study. So then we have stimulation for pacing after drug infusion. So uh code 93623 is used for the infusion or injection of drugs that are intended to alter the heart rhythm to diagnose abnormal patterns. So 93623 can be used when a drug is infused to induce or suppress an arrhythmia. This should be prior to a successful ablation of said arrhythmia. When they are using a drug stimulation only for efficacy, which means they're just checking their work. Basically, they're just making sure that the ablation uh did what it needed to do. you don't build 93623 that is intended to either um try to get a new arhythmia to um pop up or to s suppress that arhythmia. So just remember that you are not going to bill it if they did it just to check their work. Okay. Also, code 93623 may only be reported one time per encounter. do not code 93623 postpulmonary vein isolation only for checking the uh pulmonary vein reconnections and we'll talk about that a little bit more in a minute. So this is a good visual uh especially if you're going to be coding EPN ablations. This is in your CPT book. This is just a a reprint of it or a different outlook, a different version. But in your book, uh there is a version of this table and it shows you which um codes add-on codes can be built with which ablation procedures. So with uh complete EP study 93620, it tells you which codes are inherent, bundled, and not bundled. bundled which are green X's means they can be built separately for an SVT or a supra ventricular tacoc cardio ablation 93653 which is also used for a flutter it shows you inherent bundled and not bundled and obviously again not bundled means you can build them separately your VT ablation or your vent ventricular tacocardia ablation 93654 same goes as well as your PVI ablation 936 656. And I will say that um 93654 and 93656 have the least amount of non-bundled codes, meaning there's not very many things that can be unbundled or build separately. So now let's talk a little bit about normal versus um atrial fibrillation within a heart. So the visual on the left side of the screen is what we call a normal functioning heart. So you see the sinus node, the normal electrical pathways within the heart and you see the atrio ventricular node or AV node. But on the right side you see these they almost look like uh pulse stars. They are atrial fibrillation impulses within the top chambers of the heart. They cause those uh chaotic s signals within the heart which are not normal and they also can cause rapid ventricular impulses in the lower chambers of the heart. So that's what you would be seeing if someone or feeling if you're currently a patient with atrial fibrillation. So now we have supra ventricular ablations. So as we mentioned previously um this is one of the main EP ablation codes that we bill. So with 93653 the primary code um it includes a complete diagnostic EP study with or without induction of an arhythmia. So it includes the 93619 or 9362 respectively. Uh meaning you cannot build them separately. It does not include the performance of a repeat EP study following injection of conduction altering drug which is your 93623 mapping which includes the 93609 which is 2D mapping or 93613 which is 3D mapping a transceptal approach or puncture which remember we discussed earlier when we were talking about caths that's code 93462 pacing and recording ing in the left atrium which is 93621 and pacing and recording in the left ventricle which is code 93622. That means all of those codes are separately billable. 93653 is not used for the treatment of atrial fibrillation by pulmonary vein isolation technique. We have a specific code for that and that's 93656 which we will be getting into very shortly. The other code on this screen is 93655 and that is your add-on code. Meaning you have to bill a primary ablation in order to bill 93655. What is 93655? It's when they do an additional ablation for a discrete mechanism. What is a discrete mechanism? A discrete mechanism is a distinct um mechanism meaning a different um it could be if they're doing it for super ventricular um arrhythmia but then they find an a flutter. Well, that's a distinct mechanism. It's a different arrhythmia than what they originally did the ablation for. So if they find a a flutter or some other type of arrhythmia, they can do an additional ablation in bill 93655 that has what we call um a medical uh medical medically unlikely edit or MUE of two which means it can be built up to twice in addition to the primary procedure code. Our next um primary ablation is a pulmonary vein ablation or a pulmonary vein isolation. If you remember at the beginning of today's session, we discussed um that box set where they do the right pulmonary, the left pulmonary veins, and then they do the roof and the floor to make that box. That's what a pulmonary vein isolation does. So basically what they do when they go in it includes a comprehensive EP study the 93619 93620 pacing and recording in the left atrium which is the 93620 I mean sorry 93621 and the transepal puncture which is the 93462 that means you cannot build those codes separately they are included in this service. Okay. Um, code 9 uh 3656 can be done either with extremely cold temperatures or extremely hot temperatures. So, they can either do a cryoablation or they can do a a heat ablation depending on the type of um ablation that the provider feels is the most appropriate. So, with uh 93656, we only have um one add-on code specificly for AIB. That means you cannot bill 93657 with any other primary code than 93656 because it is an additional linear or focal ablation in the right or left atrium for AIB that remains after they do the primary PVI. That means once they create that box lesion set, if the patient is still in AIB after they finish that and they need to do another ablation in another area, they would bill the add-on code 93657. It also has an MU of two, which means you can only bill it two times within that session. Now that being said, the other add-on code we mentioned 93655 can be build with 93656 for a different mechanism. So if you're doing a PVI for AIB, which is the only medically necessary diagnosis you can bill with it, but they have an A flutter or they have an SVT or they have a VT arhythmia that's found, you can bill a 93655 up to twice with the 93656. And if you have both additional AIB and another mechanism, you can bill 93657 twice and 93655 twice if they are documented appropriately. So uh now we're going to cover a ventricular tacocardia ablation or what we call a VT ablation. This is going to be your 93654 and this is specifically for um uh ventricular tacocardia or VT. Again, it includes your EP study. It includes your uh mapping and your uh left ventricles. So um one thing to mention is the transceptal puncture that we discussed earlier the 93462 is not bundled with 93654. So if they do a transeptal puncture then you can bill 93462 separately. You can also bill your left atrial pacing and recording for the 93621. You can bill your drug infusion for your 93623 with your 93654. If there is an additional mechanism of arrhythmia, whether it be atrial or ventricular, you can use the add-on code 93655 that we previously mentioned and that can be for any other mechanism of arrhythmia other than ventricular tacocardia. Okay. So that will conclude today's seminar. Hopefully everyone enjoyed um this cardio boot camp with an overview of the anatomy, the diagnosis and the procedure treatment that are available within the cardio realm. Um I really appreciate everyone's time for listening today. And if you are listening to this on demand, feel free to reach out uh directly for additional questions. Um I hope everyone has a wonderful day and I hope to see you again soon. Thank you. Now we are going to go over some cardiology uh case examples. The first one is going to be a stress test and for educational purposes we will notate this to be place service 21. We will be billing for the supervising and interpreting documented for the professional component. So our codes would be 93016 and 93018. 93016 is for the supervision and 93018 is for the interpretation. 93015 and 93017 are not billable as 93015 must encompass all components which includes supervision, interpretation and the technical component for the use of the equipment and the 93017 is for the technical component only. Typically in the hospital the provider does not own their equipment and cannot bill the technical component. So now let's get into the procedure. It states that this procedure performed was a Lexi scan stress test with EKG portion. So as we previously discussed, we know that the Lexi scan is a chemical stress test instead of being an exercise stress test. So we have that this is being done for ANGA for further um ascl atherosclerosis cardiovascular disease for risk stratification. So it shows that we are doing the stress test with a pharmacological stress agent which happens to be the lexi skin. So they have injected this they are keeping up with the patient's vitals via the EKG and the blood pressure. It shows uh when the injection was done and it also shows the blood pressure readings. As you can see, it says that the findings from the EKG portion of the stress test using Lexi scan appeared within normal limits and the result or impression is a non-diagnostic EKG portion of a Lexi scan stress test. Further recommendation to follow after reviewing the images. So basically what's this saying is is they were unable to find any other reason that this patient is having cardiovascular disease with the result of the anga um sign or symptom. So ultimately uh what we are going to be billing as I previously mentioned is the 93016 for the supervision and we will be billing the 93018 for the interpretation. So our next example is going to be a um PCI with a previous diagnostic cath. So what we will be billing in this scenario is a 99152 for the moderate sedation as well as a 92928 and a 92929. And just remember we previously discussed that the 92929 will be deleted in 2026. and also to keep in mind for insurance as Medicare does not recognize the 92929. So let's get into the procedure. So this is a cath procedure. It says that it's being done for severe coronary artery disease. So our diagnosis code for this example is going to be I2510. Okay. So it states that they're doing a PCI and uh it shows that they did a primary stent to the posterior lateral artery. Okay. So the primary stent to the posterior descending artery. It also shows that uh this was a stage two um stage procedure meaning that they originally did the calath they found the coronary artery disease and this is stage two which is doing the PCI or the stint within the artery. So here we have highlighted our sedation time. It shows when the sedation time was started and when the sedation time ended. It shows you uh that they used versed fentinel uh in angomax for this procedure. It also shows that um they have documented that a diagnostic catheterization was performed several days ago and they are not intending to bill an additional cath because the only way you can bill an additional cath is if there is a change in uh the patient's condition worsening or a different indication to warrant another heart catheterization. So in this case when we are looking at this it tells us that they placed the angography carried out into the right system the guide wire was placed into the distal PLA posterior lateral artery um and they used a 2.25 * 12 mm synergy stent. So that's where you're going to get your first code, your 92928, which is for the PCI in the right coronary artery. Remember that both the PLA and the PDA are branches of the right coronary artery. So it shows that after deployment of the stent, it reduced an 80% stenosis to a 0ero to 10 uh% residual. Then once they finished with that stent, they turned their attention to the PDA osteium. They redirected the wire into the uh distal PDA. They placed another 2.25 times uh this time 15 mm stent and uh it was deployed at the origin of the PDA reducing the stenosis from 80 to 90% to a 10% or less than 10%. So in this case, our primary code was the 92928 and because this was an additional branch, we're going to build the 92929 also with the RC modifier. So as we mentioned earlier, the codes for this particular case, you're going to get the 99152 for the moderate sedation place. This is a professional fee component, so we would not be billing the 99153 as that is for the facility only. And then we have the 92928 and the 92929 both with the RC modifier. Remember you must always use your vessel modifiers when you are billing um PCI procedures. So our next example that we are covering is an EP. This is for a PVI or pulmonary vein isolation ablation procedure. And so sedation was performed by anesthesia in this procedure. Um therefore uh the EP provider would not be billing any type of anesthesia. Ultrasound guidance uh is bundled with EP procedures. So you cannot bill 76937 separately for this case. Um the uh intracardiac echo or ICE is how it's documented a lot of times is also bundled with 93656. So you will not be billing that separately. The right and left atrial pacing and recording is a required component of the PVI ablation and is not separately billable. The cavo tricuspid ablation for the AFL is considered a separate mechanism and is billable with the 93655 as an add-on code to the 93656 if you remember us going over that previously within the presentation. So, uh I'm going to scroll down so we can start the procedure and then we'll go back up to our codes. So, as you can see, they are telling you that they performed an atrial fibrillation abl ab ablation, which is the 93656. And they're also telling you they did an ablation of arrhythmia distinct from the primary mechanism, which we know from our previous discussion that that would be the 93655 if it is documented appropriately. So, our diagnosis codes are proxismal, atrial fibrillation, and atrial flutter. And we'll get to those codes in just a minute. So it shows in the documentation that the sedation was general anesthesia and it was performed by the anesthesiology provider. Therefore again we do not bill for that. So let's get into the procedure itself. As I said they place them under general anesthesia. So we will not be billing for that. The uh ultrasound guidance is bundled within this service. Therefore, we will not be billing separately for that service. It states that an 8 French ICE or intracardiac echo catheter was placed into the right atrium. So in this case, a 93656 includes the ice. Therefore, you will not be billing that separately. We move on to say that it says that they used a decanav uh decapolar um coronary sinus that's what CS stands for catheter. This was placed into the coronary sinus where it was used for right and left atrial pacing and recording. Remember that is part of the procedure. It tells us that they also did the cavo triricuspid ismas linear ablation. Now remember as we spoke about before this is a separate mechanism. The atrial flutter is separate from the a uh atrial fibrillation that we are doing the uh pulmonary vein isolation ablation for. So he tells us that they directed their attention to the cavot triricuspid ismas and that the conduction time was measured at 54 ms. So you want to see a measurement uh when they are doing this and then it tells us that they used a viso sheath and ablation catheter and the ablation was performed at 35 watts in the ISMAS. So they completed the ablation for the atrial flutter and that supports the 93655. Now moving on to our PVI ablation. They performed the transepal puncture and as we know from our previous uh part of the presentation we know that we cannot build separately for transepal puncture with a aib ablation. We already discussed the ice that cannot be separately build and then we go into the mapping for the ablation. They used a pinteray um uh electroanatomic map and remember mapping is also included in your PVI ablation. They confirmed the electrical activity in all four pulmonary veins. Remember we discussed the four areas that they ablate for a pulmonary vein isolation. Your right pulmonary vein, your left pulmonary vein, your roof, and your floor. That's called a box set. And so they tell us where the ablation is performed shoot uh using the 45 watts. Uh it talks about the esophageal temperature that was monitored just making sure that it is appropriate and not uh hurting the patient. Shows that they used a heating. Um remember I told you earlier that you can use a ablation with uh heat or you can use a cryobablation with cold. So it says the posterior wall did not have a significant amount of scar and the posterior wall ablation was not performed. So there are certain instances where they will check and if additional ablation is needed they will perform it. Okay. So at this time there was no other ablation that needed to be done. They were able to confirm and carefully remove all of the catheterss that were used for this procedure. So in closing, your procedure codes and diagnosis codes for this uh example is 93656 for the pulmonary vein isolation. And that is uh diagnosis code I48.0. So that's for proxismal atrial fibrillation and your add-on code 93655 for the atrial flutter. And because it was not specified, we use the unspecified version of this diagnosis code I4892. So that is our conclusion to today's examples. Um, if you have any further questions, feel free to reach out. I hope everyone enjoyed the uh case examples for today's session. Have a great day and I hope to see you next time. Thank you.