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.