Today we’ll be talking about Chapter 4, the Cardiovascular System Part 1. There are quite a few slides so we’re going to divide it into two parts. Some facts to remember about the Cardiovascular System: Procedures involve the heart, the pericardium, the arteries and the veins. Some parts of this section of the code book are very detailed and require advanced knowledge and coding skills. Oftentimes in hospitals, specialized coders will only code cardiac, cardiovascular and interventional radiology. It’s beyond the scope of this class to get into that much detail with you but I will provide an overview of the Cardiovascular System in this course and refer you to Appendix L in your code book which provides a reference list for the vascular families. As a review I have a diagram here for the flow of blood through the heart with veins taking blood toward the heart and arteries taking blood away from the heart and the valves keeping the blood moving in the right direction. I found this Youtube video on Khan Academy. It’s narrated very well and I give you the link here. It is closed captioned. The captioning is accurate and I encourage you to watch that just to review the flow of blood through the heart. Pacemakers or implantable cardio defibrillators: a pacemaker has two components, a generator which is a battery and one or two leads attached to the generator. It can be a single chamber, either the atrium or the ventricle or a dual chamber with one lead each, one in the atrium, one in the ventricle. A pacemaker does not provide a shock. There’s a short YouTube video there about pacemakers. An implantable defibrillator monitors heart rhythms and if those rhythms get off kilte, it will deliver a shock. It’s a short Youtube video there about the defibrillator. Both of these YouTube videos are closed captioned and are accurate. When we think about pacing devices, both the pacemaker and a defibrillator, these terms are often used. A pulse generator which is just the battery; a subcutaneous pocket which is a pocket of skin where that pulse generator is inserted into the body. It’s usually the sub clavicular, which is around your collarbone or just above your abdominal muscles.The lead or the electrode are wires that connect the pulse generator. It creates either a pacemaker system or a cardioverter-defibrillator system. Transvenous means “in the vein” is one way that the leads can be inserted into the body through the veins. The other two ways that leads can be inserted are through the epicardial location and a thoracotomy. The epicardial location is the innermost layer of the pericardium that closely surrounds the heart. You cannot get to that unless you open the chest. The thoracotomy is an opening of the chest wall required to access the epicardial location. A doctor is not going to do that unless the leads cannot be inserted intravenously for whatever reason. Here’s a diagram for a single chamber versus a dual chamber pacing devices. You see a single chamber’s pulse generator and one lead; dual chamber pacing device is a pulse generator one lead in the right atrium and one lead in the right ventricle. A bi-ventricular pacer can have three leads. In this example, there’s one lead in the right ventricle and two leads in the left ventricle. Now I want to look at some questions that have to do with pacing devices. These are not found in your textbook. Patient has a temporary transvenous pacemaker system inserted with electrodes placed in the right atrial and the right ventricular chamber. So you know it’s a dual right there. The table is one way that you as a coder can be sure that you’re granted all the questions that you need to answer in order to assign a code. It also helps you by going through these steps to be able to pick out your main term, what you’re going to look for in the index. Temporary we’re going to code it there. A pacer is either temporary or permanent. If it does not say, then we assume it is permanent and then the leads are implanted either by thoracotomy, epicardial or transvenous. In this case, it tells us it’s transvenous pacemaker so once we have all those parts the answer is 33211. As a reminder, when you’re going through these powerpoints I’ve tried to put the question on a slide before the one with the answer so that you can attempt to look it up and then check your answer moving forward in the PowerPoint. Here’s the code in the code book. As a reminder, in my annotation system for my code book, if a code has an underline under it, it means there is no family. This code stands by itself and is complete within itself It is insertion or replacement of a temporary transvenous dual-chamber pacing electrode. You see there are two references to CPT Changes and CPT Assistant (publications) if we want to look up how we came to this code. Here’s another pacing device exercise not in the textbook. A patient had a transvenous dual lead pacemaker system inserted. A reminder, if the documentation doesn’t say temporary, we’re going to code it as permanent. I shortened up my questions from the table in the previous slide to just answer the What? The intent? The type? The how? and How many? I pulled out my answers and those first two terms, pacemaker and insertion, are going to be the main terms I would look at in the index and my answer is 33208. There was a range of codes in the index and we just started looking at them, reading the code descriptions until we got to the one that described what we have here. Here it is in the codebook. I purposely did not blow this up so that you can see the family of codes. I have it circled. 33206 is the parent code and then the next two codes are alternative versions by adding different language after the semicolon. Our answer is 33208 which is read insertion of new or replacement of permanent pacemaker with transvenous electrode, atrial and ventricular. Also be sure and read those notes that are under the codes. I’ve highlighted here a reminder to me that subcutaneous insertion of the generator and transvenous placement of the electrodes is included. Okay, here’s another pacing device exercise. This one is in your homework for the Cardiovascular System. A patient with a previously implanted pacing cardioverter-defibrillator now requires repositioning of the lead and there’s our answer. Repositioning is the main term we will look for in the index. We are repositioning the electrode or the lead and here is the code. It stands alone 33215. I have a little underline (because it stands alone). Repositioning a previously implanted transvenous pacemaker or implantable defibrillator, right atrium or right ventricular electrode. As a reminder, when I’m showing you the code book at the top in red, that is the part of the Cardiovascular System that we are looking at and in blue is the section of procedures on the heart or pericardium we’re looking at. As I mentioned earlier, cardiac valves keep the blood moving in the right direction through the heart. The three cardiac valves that we know about are the Mitral, Tricuspid and Aortic valves. There are many procedures in the CPT book. The one I’m choosing to talk about a little more is the TAVR, which is a transcatheter aortic valve replacement . This is a collapsible aortic heart valve that’s placed by using a catheter that’s inserted through a small incision in the femoral artery.There’s an extensive set of notes in the codebook that’s printed before the code 33361. You really have to read those (notes). The next exercise comes from our textbook 4.23 #8, the patient’s been diagnosed with severe aortic stenosis. Through a percutaneous incision in the leg, which would be transfemoral, the surgeon performs a transcatheter aortic valve replacement or a TAVR. I decided with this main term I would look up the abbreviation first because I don’t often do that and when I did, it sent me to another place in the index, the transcatheter aortic valve replacement. When I went there, there’s an option for the femoral artery approach with two codes. I went to the CPT book, read those code descriptions and chose my answer 33361. Now let’s talk about CABGs. CABG stands for coronary artery bypass grafting. There are two series of codes in the CPT book that have to do with what the procedure is using as far as grafts. The first series of codes is reported when the CABG uses only venous grafts, like the saphenous vein. Saphenous vein is in the leg. It’s most commonly used in these CABG procedures. If you don’t know where it is exactly, you can go to the other parts of your boo,k your code book, that have illustrations that you can look and see where the saphenous vein is. You as a coder would review the operative report to determine the number of coronary venous grafts that were performed. The second series of codes describes the CABG that uses both arterial and venous grafts. For example, the saphenous vein usually provides the venous grafts and the arterial graft is usually created from the internal mammary artery. Whenever the procedure is a combined arterial venous bypass grafting, two codes have to be assigned, one from each of these groups. Let’s do one of these questions. This is Exercise 4.23 #10. The CABG was performed. The surgeon bypassed three coronary artery sites by grafting the left internal mammary artery and one side was treated by grafting the greater saphenous venous graph to the obtuse marginal from the aorta. So when you look in your index, you see there are three terms under the CABG term for the arterial bypass, the arterial venous bypass and the venous bypass. You look up your codes and here’s the two answers. I pulled this slide just to show you when it says read the guidelines, it’s not kidding. You really do have to read the guidelines and you see here there’s guidelines for the venous grafting only, arterial grafting and the combined arterial venous grafting for the bypass. You really need to read all three of those. They’re not very long. Be sure that you are capturing everything you need to capture when you’re reading the operative report. Here’s the first of those two codes. 33517 and you see I have it circled on a family of codes. Only two codes and my family are showing. We are choosing the single vein graft 33517 for the first code and our second code 33535 for three coronary arterial grafts. The ECMO or ELSS codes were introduced to identify those procedures for patients who are on cardiac or respiratory life support. These patients have hearts and lungs that no longer function. You choose your codes differentiated by the age of the patient, whatever service is provided and the type of cannulation. In other words is it peripheral or central? I’m not going to go through any examples of that because you you wouldn’t be coding very many of those. I just want you to be aware of those acronyms. More facts to remember- Let’s talk about the arteriovenous fistulas. A fistula is created by the surgeon connecting an artery to a vein. That very abnormal connection causes more blood to flow from the artery to the vein under high arterial pressure. Eventually the vein wall gets stronger and thicker and can withstand the continuous punctures that is going to happen when a patient is undergoing hemodialysis. If you don’t know, for a patient who is undergoing hemodialysis, it’s not unusual for them to go two or three times a week and have their arm punctured and be hooked up to a machine that over several hours filters all the toxins out of their blood, just as the kidneys would do if they were functioning correctly. Those repeated sticks- a normal vein is just not going to tolerate that. It’s going to collapse and it’s not going to tolerate being stuck so much. So when a patient’s getting ready to have hemodialysis, the doctors will oftentimes create this fistula and sometimes it can take several months to mature. Mature meaning that the wall has gotten strong enough and thick enough to withstand those repeated sticks. CPT codes are based upon whether the fistula was created by a vein transposition or direct anastomosis. If it was a vein transposition, the code is assigned according to the vein that was used and if it’s a direct anastomosis method, that is involving attaching an artery and vein directly. If the creation of the AV fistula is not possible, if the creation of the AV fistula is not possible, the surgeon may use a graft to connect the artery to the vein. An arteriovenous graft requires less time to mature than an arteriovenous fistula. A disadvantage to AV grafts is that they often produce blood clots where they become infected. Those complications that exist around AV fistulas and grafts require certain procedures to help the fistula or the graft be able to do its job. The CPT codes cover the procedures that are necessary to correct those complications. That would include an angioplasty, a stent placement or a thrombectomy. Thrombectomy is removal of a clot. It can be performed with or without revision of the graft and it can be performed either open or percutaneously. Let’s look at the complications in little more detail especially a thrombectomy. Apercutaneous thrombectomy of a graft is coded with the code 36870. That includes all the work required to restore flow to the access. That thrombus, that blood clot can be removed with drugs like urokinase or mechanically removed. In addition to the 36870, additional procedures may be reported to identify the punctures of the graft. Two punctures are usually performed with arterial and venous and they will be reported with 36147 and 36148. Let’s look at this exercise. This one threw me. I want to explain to you why. I had not taken the time to look at the new codes for 2017 so I had to do a little work here to figure out what this code was. When you go to thrombectomy and you look up the AV fistula and the graft, you get this range of codes. But when you go to the code book and you read the descriptions (of the codes) in that range, all those procedures are “open” procedures; they’re not percutaneous procedures. So I knew something wasn’t right. I went back to the index under thrombectomy, looked under percutaneous and looked at the terms under percutaneous and the only one that had anything to do with the fistula was a dialysis circuit. It gives me a range of codes. So then when I went back, like I should have done that the first time, went back into the code book, read those pages that talk about the “dialysis circuit”. Then I understood what the codes meant and why I couldn’t find the code. Then when I went to the actual code 36904 and saw that little symbol for “new code”, well no wonder. So case in point, even if you’ve been coding a long time, you really need to look at what the new codes are each time the code book comes out new. So there you go. Here’s the code in the code book. I actually wrote beside it “new code” to remind myself. That red circle is what tells us it’s a new code. When I read the descriptions, it’s very clear 36904 does describe what we were reading. You notice my circle’s not complete so that means there are more codes within this family of codes if you read further down the column.That’s all we’re going to do for Part one. Our next recording will be Cardiovascular System Part two.