4A-Have A Heart Cardiology Coding - AAPC

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10/10/2012Have a Heart:Cardiology CodingAAPC Regional ConferenceOctober 25-27, 2012ChicagoPresented by: Betty A Hovey, CPC, CPMA, CPC-I, CPC-H, CPCDDirector, ICD-10 Development and TrainingAAPCAgenda Anatomy of the heartCardiovascular diseasesCommon Cardiology ICD‐9‐CM codesCABGValve proceduresPacemakers and defibrillators1

10/10/2012We’ve come a looooooooong wayElectrocardiogram32

10/10/2012Chambers and valvesOxygenation Process1. Deoxygenated blood enters into right atrium throughsuperior or inferior vena cava2. Tricuspid valve opens and blood drops into right ventricle3. Pulmonary valve opens, and deoxygenated blood movesthrough it into pulmonary artery4. Pulmonary artery sends the blood to the lungs whereoxygenation occurs at the capillary beds5. Oxygenated blood enters back into left atrium throughpulmonarylvein6. Mitral valve opens and blood drops into left ventricle7. Aortic valve opens and ventricular muscle pumps blood upand out into the body through the aorta63

10/10/201274

10/10/2012Coronary Heart Disease CCoronary hearth t diseasedi(CHD) isi a narrowingi off thethsmall blood vessels that supply blood and oxygen tothe heart. CHD is also called coronary artery disease(CAD). CCoronary artery diseasediiis theh lleadingdi cause off ddeathhin the United States for men and women.9Coronary Heart DiseaseSymptoms Chest pain or discomfort (angina) (most common) Chest heaviness/ Squeezing Pain usually occurs with activity or emotion, andgoes away with rest / nitroglycerin. Shortness of breath Fatigue with exertion105

10/10/2012Baseline US age-standardized death rates from cardiovascular diseases, 2006.Roger V L et al. Circulation 2011;123:e18-e209Copyright American Heart AssociationPercentage breakdown of deaths due to cardiovascular disease (United States: 2007).Roger V L et al. Circulation 2011;123:e18-e209Copyright American Heart Association6

10/10/2012CAD ICD‐9‐CM 414.00 Coronary atherosclerosis of unspecified type ofvessel, native or graft 414.01of native coronary artery 414.02of autologous vein bypass graft 414.03of nonautologous biological bypass graft 414.04of artery bypass graftptypeyp of bypassyp ggraft 414.05of unspecified 414.06of native coronary artery of transplanted heart 414.07of bypass graft of transplanted heartAngina ICD‐9‐CM 411.1 Intermediate coronary syndrome 413.0 Angina decubitus 413.1 Prinzmetal angina 413.9 Other and unspecified angina pectoris7

10/10/2012Myocardial InfarctionICD‐9‐CM Code consideration:– Acute/Chronic/Old– Specific site– STEMI or NSTEMI– Episode of careHeart Failure ICD‐9‐CM428.0 Congestive heart failure, unspecified428.1 Left heart failure428.20 ‐428.23 Systolic heart failure428.30 – 428.33 Diastolic heart failure428.40 – 428.43 Combined systolic anddiastolic heart failure 428.9Heart failure, unspecified 8

10/10/2012Valve Disorders Considerations for codes– Valve(s) affected– Type of disorder– RheumaticValve DisordersRheumaticNot specified as rheumatic 394.1 Rheumatic mitralstenosis 395.1 Rheumatic aorticinsufficiency 397.1 Rheumatic diseases ofpulmonary valve397 0 Disease of tricuspid 397.0valve 424.0 Mitral valve disorders 424.1 Aortic valve disorders 424.2 Tricuspid valvedisorders 424.3 Pulmonary valvedisorders9

10/10/2012Valve DisorderDisease of mitral and aortic (whether specifiedas rheumatic or not)396.0 Mitral valve stenosis and aortic valve stenosis396.1 Mitral valve stenosis and aortic valveinsufficiency396.2 Mitral valve insufficiency and aortic valvestenosisti396.3 Mitral valve insufficiency and aortic valveinsufficiencyConduction Disorder Considerations for codes– Complete– Type– Right– Left– Right and Left– Other10

10/10/2012Conduction Disorders 426.0 Atrioventricular block, complete426 11 First degree atrioventricular block426.11426.12 Mobitz (type) II atrioventricular block426.2 Left bundle branch block426.4 Right bundle branch block426 51 Right bundle branch block and left426.51posterior fasicular blockCABGCORONARYARTERYBYPASSGRAFTBJ&A, 2009. ALL RIGHTS RESERVED.2211

10/10/2012CABG – Coding (33510 – 33536) From a coding perspective, the important issues forthe coder to know are the following:How many grafts were performed?How many were arterial?How many were venous?What was used to perform the graft(s)? Radial artery,saphenoushvein,i etc.Did the patient have a previous CABG procedureperformed?CABGThe number and type of graft holds a directcorrelation to the CPT code(s) that will be used.If a patient has only venous grafting performed thefollowing code range is applicable:33510 – 33516Venous Grafting ONLY forCoronary Artery BypassIf a ppatient has onlyy arterial ggraftingg pperformed thefollowing code range is applicable:33533 – 33536Arterial Grafting for CoronaryArtery Bypass12

10/10/2012CABGIf a patient has both arterial and venous graftingperformed then two codes must be reported fromthe following code ranges:33517 – 33523 Venous Grafting for CombinationCoronary Artery BypassNote: These are add‐on codesAND33533 – 33536 Arterial Grafting for CoronaryArtery BypassCABGEXAMPLESPatient has a 3 venous only CABG33512Patient has a 2 arterial only CABG33534Patient has a 3 venous, 2 arterial CABG33534, 3351913

10/10/2012CABGProcurement of the Conduit When it is bundledWhen it is not bundled35600 ‐ UEA35500 ‐ UEV35572 – FemFem‐poppop33508 – Endo harvestCABG“Re‐do”If a patient has had a prior CABG, the coder must beaware of an additional code. The procedure wouldbe coded as if it was being performed for the firsttime, but then add‐on code 33530, Reoperation,coronary artery by pass procedure or valveprocedure, more than one month after the originaloperation, would be reported also.14

10/10/2012Valve Disease/Disorder Congenital valve disease Bicuspid aortic valve disease Acquired valve disease Mitral valve prolapse (MVP)Valve Repair/ReplacementA prosthetic (artificial) heart valve is a replacement for adiseased or dysfunctional heart valve. There are twotypes of artificial valves: Mechanical heart valveA mechanical heart valve is made of man‐madematerials. The advantage of mechanical valves is thatthey can usually last a lifetime. They do not wear outth way naturalthet l or biologicalbi l i l valvesldo.d15

10/10/2012Valve Repair/Replacement Biological heart valveBiological heart valves are made from tissue takenfrom animals or human cadavers. They are treatedwith preservatives and sterilized for humanimplantation.BJ&A, 2010. ALL RIGHTSRESERVED.31Starr‐Edwards Silastic ball valvemitral Model 61203216

10/10/2012Medtronic Hall mitral valve33St. Jude Medical mechanical heartvalveBJ&A, 2010. ALL RIGHTSRESERVED.3417

10/10/2012Valve Repair/ReplacementThe four key types of biological valve replacements are: Pig valves which are actual transplants from the heartof a pig. Cow valves which are made from the pericardial tissueof a cow’s heart.gwhich are human donor valves. Homografts Autografts which are the patient’s own valve used inthe Ross Procedure.Carpentier‐Edwards Mitral Valve3618

10/10/201237Valve Repair/ReplacementCPT codes will depend on the following: Which valve? Repair or replace? Replaced with prosthetic? Type? Was patient on cardiopulmonary bypass?19

10/10/2012Valve Repair/ReplacementAortic Valve Procedures33400‐33417Mitral Valve Procedures33420‐33430Tricuspid Valve Procedures33460‐33468Pulmonary Valve Procedures33470 3347833470‐33478BJ&A, 2010. ALL RIGHTSRESERVED.39Example ‐ 33405PROCEDURES: Aortic valve replacement using a mechanical valveINCISION: Median sternotomyINDICATIONS: The patient presented with severe congestive heart failure associated withthe patient's severe diabetes. The patient was found to have moderately stenotic aorticvalve.l It was ddecidedd d to performfa valvel replacement.lFINDINGS: The left ventricle is certainly hypertrophied The aortic valve leaflet is calcifiedand a severe restrictive leaflet motion. It is a tricuspid type of valve.PROCEDURE: The patient was brought to the operating room and placed in supineposition. A median sternotomy incision was carried out. The patient weighs nearly threehundred pounds.The patient went on cardiopulmonary bypass and the aortic cross‐clamp was appliedCardioplegia was delivered through the coronary sinuses in a retrograde mannermanner. Thepatient was cooled to 32 degrees. Iced slush was applied to the heart. The aortic valvewas then exposed through the aortic root by transverse incision. The valve leaflets wereremoved and the mechanical valve was secured into position by circumferential pledgetedsutures. At this point, aortotomy was closed.20

10/10/2012Pacemakers/Defibrillators2012 CPT New/Revised CodesNEW GUIDELINES PACEMAKER OR PACINGCARDIOVERTER‐CARIOV RT R DEFIBRILLATORFI RI ATOR Use of term implantable cardio‐verterdefibrillator (ICD) Change in codes included in electrode work New “battery” guidelines21

10/10/20122012 CPT New/Revised CodesNEW GUIDELINES PACEMAKER OR PACINGCARDIOVERTER‐ DEFIBRILLATORCARDIOVERTER Pacer / ICD evaluation codes Radiologic S&I Definitions2012 CPT New/Revised CodesNEW GUIDELINES PACEMAKER OR PACINGCARDIOVERTER‐CARIOV RT R DEFIBRILLATORFI RI ATOR Pacer / ICD evaluation codes Radiologic S&I Definitions22

10/10/20122012 CPT New/Revised Codes 33050 Excision Resection of pericardial cyst ortumorʘ 33206 Insertion of new or replacement ofpermanent pacemaker with transvenouselectrode(s); atrialʘ 33207 ventricularʘ 33208 atrial and ventricularEXAMPLEA patient presents for removal andreplacementlt off a ttransvenous dduall chamberh bcardiac pacemaker.33208, 33235, 3323323

10/10/20122012 CPT New/Revised Codesʘ 33212 Insertion or replacement ofpacemakerk pulsel generatort only;lsingle chamber, atrial or ventricular withexisting single leadʘ 33213 with existing dual chamber leadsʘ# 33221 with existing multiple leads2012 CPT New/Revised Codesʘ 33218 Repair of single transvenouselectrode for a single chamberchamber,permanent pacemaker or single chamberpacing cardioverter‐defibrillator;ʘ 33220 Repair of 2 transvenous electrodespfor a dual chamber permanentpacemaker or dual chamber pacingcardioverter‐defibrillator;24

10/10/20122012 CPT New/Revised Codes 33224 Insertion of pacing electrode, cardiacvenous system,tffor lleftftventricular pacing, with attachment topreviously placed pacemaker or pacingcardioverter‐defibrillator pulse generator(including revision of pocketpocket, removalremoval,insertion, and/or replacement of existinggenerator)2012 CPT New/Revised Codes 33225 Insertion of pacing electrode, cardiacvenous system,tffor lleftftventricular pacing, at time of insertion ofpacing cardioverter‐defibrillator or pacemakerpulse generator (including upgrade to dualchamber systemyand ppocket revision)) (List(separately inaddition to code for primary procedure)25

10/10/20122012 CPT New/Revised Codes 33226 Repositioning of previously implantedcardiac venous system (leftventricular) electrode (including removal,insertion and/or replacement of existinggenerator);2012 CPT New/Revised Codesʘ 33240 Insertion of single or dual chamberpacingi cardioverter‐defibrillatordit d fib ill tpulse generator only; with existing single leadʘ# 33230 with existing dual leadsʘ# 33231 with existing multiple leads26

10/10/20122012 CPT New/Revised Codesʘ 33241 Subcutaneous removal Removal ofsingle or dual chamber pacing cardioverter ‐defibrillator pulse generator onlyʘ# 33262 Removal of pacing cardioverter‐defibrillator with replacement of pacingcardioverter‐defibrillator pulse generator; singlelead systemʘ# 33263 dual lead systemʘ# 33264 multiple lead systemEXAMPLEA patient presents for a new battery in hissingle lead pacing cardioverter‐defibrillator.33262(Do not report 33262‐33264 in conjunctionwith 33241)27

10/10/20122012 CPT New/Revised Codesʘ 33249 Insertion or repositioningreplacement of electrode permanentpacing cardioverter‐defibrillator system withtransvenous lead(s) for, single or dualchamber ppacingg cardioverter‐defibrillator andinsertion of pulse generatorPacemakers/DefibrillatorsCPT codes will depend on the following: WhatWh t was ththe approach?h? Transvenous/epicardialT/ i di l Type of device? Permanent or temporarypacemaker/defibrillator/single or dualchamber/biventricular TType off procedure(s)d ( ) eposition/removal with replacement/insertion28

10/10/20122012 CPT New/Revised Codes 33233 Removal of permanent pacemakerpulsel generatort onlylʘ# 33227 Removal of permanent pacemakerpulse generator with replacement ofpacemaker pulse generator; single lead systemʘ# 33228 dual lead systemʘ# 33229 multiple lead systemTesting 93279‐93299 Programming device evaluation 93640, 93641 Defibrillator threshold testing(DFT)29

10/10/201293279‐93299 May not be reported in conjunction with pulsegeneratort andd leadl d insertioniti or revisioni i codesd– 33206 – 33249 Pacers ICDs ILRsILR93279 ‐ 93299 Components that must be evaluated:– Pacemaker: programmed parameters, lead(s),battery, capture and sensing function, and heartrhythm– ICD: programmed parameters, lead(s), battery,capture and sensing function, presence orabsence of therapy for ventriculartachyarrhythmias and underlying heart rhythm30

10/10/201293279 ‐ 93299 Components that must be evaluated:– ILR: programmed parameters and the heartrhythm during recorded episodes from bothpatient93279 ‐93299 Interrogation device evaluation(s)– Remote– Some codes for up to 30 days (not reported if lessthan 10 days)– Some codes for up to 90 days (not reported if lessthan 30 days)31

10/10/201293640,93641 93640 ‐ Electrophysiologic evaluation of singleor duald l chamberh b pacingi cardioverter‐ditdefibrillator leads including defibrillationthreshold evaluation at time of initialimplantation or replacement 93641 – with testingg of singleg or dual chamberpacing cardioverter‐defibrillator pulsegeneratorRadiologic Radiologic supervision and interpretationrelatedl t d tto theth pacemakerk or pacingicardioverter‐defibrillator procedure is bundled Fluoroscopic guidance for diagnostic leadevaluation without lead insertion,insertionreplacement, or revision procedures, use76000.32

10/10/2012Resources ICD‐10‐CM Anatomy and PathophysiologyAmerican Heart Association2012 CPT Professional Edition2012 ICD‐9‐CMDreamstimeDDR MediaRH BulbulQUESTIONS?THANK YOU!ENJOY THE REST OF THECONFERENCE33

7 CAD ICD‐9‐CM 414.00 Coronary atherosclerosis of unspecified type of vessel, native or graft 414.01 of native coronary artery 414.02 of autologous vein bypass graft 414.03 of nonautologous biological bypass graft 414.04 of artery

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