CV Notes.htm

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Northeast Wisconsin Technical College *

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Medicine

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Jan 9, 2024

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CPT CODING -- CARDIOVASCULAR SYSTEM Coronary Artery Bypass Grafting Patients with severe coronary artery disease might need to have coronary artery bypass grafting (CABG). A bypass graft is like a highway bypass that goes around a city. A highway bypass allows traffic to flow from one end of the city to the other end by going around the city. The same is true of the coronary bypass - blood flows from one part of the coronary artery to another by going around the blockage. To see some images of a coronary bypass, please go to External Links folder within this Learning Plan. When coding coronary artery bypass grafting (CABG) procedures, you need to answer the following two questions before selecting the CPT code(s). 1. What type(s) of vessel was used for the bypass (artery, vein, both)? 2. How many coronary arteries were bypassed? To determine the number, count the number of distal anastomoses (contact points) where the bypass graft artery or vein is sutured to the diseased coronary artery(s). Practice Exercise 1: Let’s look at a few diagrams of CABGs. For each diagram, determine the type of graft vessel used and the number of coronary arteries bypassed. DIAGRAM A:

DIAGRAM B: DIAGRAM C:

How did you do? Check your answers . Please post any questions in the Discussion Board. The next step in coding CABGs is to determine the range of CPT codes that should be used. Type of Graft Vessel Used CPT Code Range Veins Only 33510-33516 Arteries Only 33533-33536 Arteries and Veins 33533-33536 AND 33517-33523 The instructional notes and diagrams in the CPT code book in this area (codes 33510- 33536) are definitely worth reading! Please take a few minutes and read through these notes. Notice that procurement (harvesting) of the saphenous vein graft is included in the CABG codes and should not be coded as a separate service.

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Practice Exercise 2 Let's give this a try. Using the following scenarios, 1) determine the type(s) of graft vessel used; 2) determine the number of coronary arteries bypassed; and 3) assign the CPT code(s). Scenario A : Coronary artery bypass grafting was accomplished using saphenous vein grafts. The first vein graft went from the aorta to the diagonal branch of the left coronary and in sequential fashion to the obtuse marginal branch of the circumflex. The next graft went from the aorta to the right coronary artery. The final vein graft extended from the aorta to the left anterior descending coronary artery. Scenario B: The first bypass graft was performed by connecting the left internal mammary (thoracic) artery to the left anterior ascending coronary artery. Next, a saphenous vein graft was used to bring blood from the aorta to the obtuse marginal branch of the circumflex artery. Another vein graft was used to bypass the diagonal artery and a final vein graft was used to bypass the proximal posterior descending coronary artery. Did you get it? Check your answers . Please post any questions on the Discussion Board. Rule of Thumb To determine the number of bypass grafts in a coronary artery bypass graft (CABG) procedure, count the number of distal anastomoses (contact points) where the bypass graft vessel(s) is sutured to the coronary artery. Practice Exercise 3 Let's try coding a coronary artery bypass procedure by using the documentation in an operative report. Assign CPT code(s) to the following case. Please pay close attention to the text that is highlighted. INPATIENT OPERATIVE REPORT Preoperative Diagnosis: Severe coronary artery atherosclerotic disease. Postoperative Diagnosis: Same. Operation : Coronary artery bypass x 4 with left internal mammary artery to left anterior descending; right internal mammary artery to the right coronary; saphenous vein from

aorta to obtuse marginal; and saphenous vein from aorta to diagonal. Description : The patient was brought to OR and placed under general endotracheal anesthesia. The patient was prepped and draped in the usual sterile fashion. Simultaneous mid-sternotomy and saphenous vein harvest from the right lower leg were carried out. The saphenous vein was prepared to use as a conduit. The left internal mammary and right internal mammary were taken down to use as conduits as well. The patient was placed on cardiopulmonary bypass and cardioplegia was administered. Grafting was carried out in the following sequence. Right internal mammary was grafted end-to-side to the main right coronary artery just below the takeoff of the two acute marginals. Saphenous vein grafting was performed from the aorta end-to-side to the obtuse marginal. Saphenous vein grafting was performed from the aorta end-to- side to the diagonal. Left internal mammary was grafted end-to-side to the left anterior descending coronary artery. There was good flow and no leaks at the anastomoses. Hemostasis was maintained. Cardioplegia was reversed. The patient was weaned from cardiopulmonary bypass without difficulty. Chest tubes were placed. Sternal wires were placed. The fascia, subcutaneous, and skin were closed. The patient was transported to ICU in stable condition. That wasn't so bad, was it? Check your answers . Please post any questions on the Discussion Board. Permanent Cardiac Pacemaker Insertion The instructional note in the CPT code book under "Pacemaker or Pacing Cardioverter- Defibrillator" provides a description of some of the pacemaker terminology. Let's take a look at some of the pacemaker terms . When coding permanent cardiac pacemaker insertion, you need to answer the following questions: 1. Is the electrode(s) (leads) epicardial or transvenous? 2. If transvenous, is the electrode(s) inserted into the atrium, ventricle or both? Be sure to review the guidelines for this subsection in CPT. There is now a table to make coding of pacemakers and cardioverter-defibrillators much easier. Simply identify on the left side what procedure is being performed and then move to the right to specify if the procedure is done for a pacemaker or a cardioverter-defibrillator. Permanent Cardiac Pacemaker Replacement When coding replacement of permanent cardiac pacemakers, you need to answer the following questions:

1. What part(s) of the cardiac pacemaker system is being replaced (pulse generator, electrodes)? 2. What part(s) of the cardiac pacemaker system is removed (pulse generator (battery), electrodes)? There are also CPT codes for upgrade, repair and revision of cardiac pacemaker systems components. Practice Exercise 4 Give this case your best shot! Assign CPT code(s) to the following case. Please pay close attention to the text that is highlighted.

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OPERATIVE REPORT Preoperative Diagnosis : Elective replacement of permanent dual chamber pacemaker. Postoperative Diagnosis : Same. Procedure : Permanent pacemaker replacement. Description : The patient was brought to the Cardiac Catheterization Laboratory and placed on the table. His left shoulder and chest were prepped and draped in the usual sterile fashion. Under local anesthesia, the old incision was opened and carried down to the pacemaker pocket. The pulse generator was then removed and was quickly attached to the temporary pacing system. Atrial and ventricular leads were evaluated and found to be functioning well and therefore were retained. The new pulse generator, Intermedics Relay, Model 293-03, Serial # KL1236, was then taken and affixed to the chronic leads with the set screws and secured. The ventricular lead parameters showed pacing threshold of 0.9 volts with a current of 2.1 milliamps and resistance of 440 ohms. Threshold at 2.5 volts was 0.1 milliseconds. Sensing was not tested due to the very slow underlying rhythm. Atrial lead showed P- waves of 1.8 to 2.2 millivolts, with a pacing threshold of 1.0 volts, current of 2.3 milliamps and resistance of 450 ohms. Threshold at 2.5 volts was 0.1 milliseconds. The pacemaker pocket had been copiously irrigated with antibiotic solution and hemostasis had been obtained with Bovie cautery. T he pulse generator was placed in the pocket with the leads inferior to the pulse generator can. The wound was closed in a sequential fashion using 0 Vicryl on the fascial layer and 3-0 Vicryl on the subcuticular layer and skin. There were no complications. Blood loss was estimated at less than 20 cc. The patient was taken to the recovery area in good condition. Coding this one was a piece of cake, wasn't it? Check your answers . Please post any questions on the Discussion Board. Central Venous Access Procedures (including central venous catheters and venous access devices) The paragraphical information at the beginning of this section has very important information for assignment of theses codes. To qualify as a central venous access catheter or device, the tip of the catheter/device

must terminate in the subclavian, brachiocephalic (innominate) or iliac veins, the superior or inferior vena cava or the right atrium. If the catheter or devices does not terminate in one of these places, this is not the section of codes you should be choosing from. Questions to ask yourself when coding central venous access procedures (central venous catheters, central lines, central venous access devices, etc): 1. Is the catheter centrally inserted or peripherally? a. Centrally Inserted = Catheter entry site is the jugular, subclavian, femoral vein or inferior vena cava. b. Peripherally Inserted = Catheter entry site is the basilic or cephalic vein 2. Was the catheter tunneled? A tunneled catheter is inserted into a central vein and the remainder is tunneled subcutaneously to a distant exit site. Tunneling helps secure the catheter in place and reduces the incidence of infection. A nontunneled catheter is inserted directly into a central vein and is associated with a higher risk of infection. The location varies as well: A tunneled catheter is inserted in the chest; a nontunneled in either the chest or the neck. Also, a tunneled catheter is usually placed in a surgical or radiology suite while a nontunneled catheter can be inserted quickly at the bedside (making it a good choice in an emergency situation). A tunneled catheter may remain in place for several months to years while a nontunneled catheter usually has a dwell time of less than a month. The documentation in the operative report/procedural report must be clear that the physician is tunneling the catheter. 3. Was a pump or port inserted also? 4. What is the age of the patient? Be certain you know the answers to the above 4 questions because they will make a difference in the code assignment. It is also important that you pay close attention to the five categories (Insertion, Repair, Partial Replacement, Complete Replacement, & Removal). Please notice there are a lot of parenthical information in this section also. Paying close attention to both the paragraphical and parenthical information will help you choose the most appropriate code. The table in your CPT Coding book is helpful when trying to narrow down the code to the correct one--be sure you always review the full description of the procedure code before assigning it.

Practice Exercise 5 Here we go again! Assign CPT code(s) to the following case. Please pay close attention to the text that is highlighted. OPERATIVE REPORT Preoperative Diagnosis: Retroper itoneal Burkitt's lymphoma. Postoperative Diagnosis: Same. Operation/Proced ure: Placement of Groshong catheter. Description: This 48-year-old patient was taken to surgery, and the procedure was performed under local anesthesia using 0.25% Marcaine with epinephrine and sodium bicarb along with IV sedation from the Anesthesia Department. Both chest and shoulders were prepped and draped in a sterile fashion. After infiltration of local anesthesia, the right subclavian vein was entered on the first stick. The J-wire passed easily into the superior vena cava as shown by fluoroscopy. The dilator and peel-away sheath was passed over the wire. The wire and dilator were removed, and a single-lumen Groshong catheter was advanced through the peel-away sheath up to the cuff. Peel-away sheath was removed. The outside end of the Groshong was tunneled in the anterior chest wall and exited superior and medial to the right breast. We were able to inject saline easily and aspirate blood easily. Catheter was fixed at its exit point through the skin with two lasso stitches of nylon. The patient tolerated the procedure well and was taken to recovery room. Postoperative chest x-ray is planned. What code did you come up with? Check your answers . Please post any questions on the Discussion Board. Arteriovenous Fistula and Anastomosis Procedures Creation of an arteriovenous fistula or anastomosis is a procedure done for hemodialysis access in which a new connection is made between an artery and a vein. An arteriovenous fistula involves using a vessel to connect an artery with a vein. The vessel may be one of the patient's own blood vessels (autogenous graft - 36825) or a synthetic vessel (nonautogenous graft - 36830). Please refer to the diagram in the CPT code book for codes 36825-36830. An arteriovenous anastomosis involves directly connecting an artery and vein without

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the use of a graft. Please refer to the diagram in the CPT code book for code 36821. Practice Exercise 6 Let's try coding again! Assign CPT code(s) to the following case. Please pay close attention to the text that is highlighted. OPERATIVE REPORT Preoperative Diagnosis: Retroperitoneal Burkitt's lymphoma. Postoperative Diagnosis: Same. Operation: Left radial artery to cephalic vein Cimino fistula. Anesthesia: 0.5% Carbocaine local with monitored anesthesia care. Description: Following mild IV sedation, standard prep and drape and routine infiltration of 0.5% Carbocaine local in the forearm, an incision was made, carried down to the subcutaneous tissues and dissection was then carried out laterally where the cephalic vein was identified at a branch point. The distal two branches were ligated. The vein was dissected back for a workable length, transected at the branch points, where a large splayed anastomosis could possibly be made and here the vein was opened and easily dilated up to a #3 mm size which passed all the way to the hilt up the arm. The vein was flushed with heparin and controlled with a bulldog clip. The fascia was then anesthetized and opened and the radial artery was dissected out for a workable length requiring ligation of several small side branches. This was opened with an #11 blade and Potts scissors under control of vessel loops proximally and distally. It was sized easily up to a 2.5 mm size and flushed with heparinized saline proximally and distally. Following this an end-to-side anastomosis with running #7-0 Prolene was performed vein to artery and the graft had excellent flow in it upon removal of all clips. The wound was irrigated with Kantrex antibiotic irrigant and closed with multiple interrupted #4-0 Maxon deep sutures and running #5-0 Prolene in the skin. The patient tolerated the procedure well and was taken to the recovery room in stable condition. What did you come up with? Check your answers . Please post any questions on the Discussion Board.

Words of Wisdom Being able to find information and use references efficiently is a tremendous skill for coding specialists to possess. You don't have to remember everything, but knowing where to look and how to interpret and apply information is critical. Keeping these Class Notes (and your additions) organized, either in electronic or paper format, will be helpful for the final examination and also in your future coding position. As mentioned in an earlier module, the official coding publication for CPT advice is the CPT Assistant, published by the American Medical Association. Past issues of CPT Assistant contain some valuable coding advice and scenarios related to coding CABGs and venous catheter and access device procedures. A good coding specialist knows when and how to use references to find current information! Cardiac Valve Replacement When coding cardiac valve replacement, the coding specialist must answer the following questions: 1. Which valve(s) is being replaced (aortic, mitral, tricuspid, pulmonary)? 2. If aortic, what type of valve is being used as the replacement valve? The choices for valve replacement are mechanical, bioprosthetic, homograft or autograft. Mechanical valves (St. Jude, Medtronic-Hall, etc.) require long-term anticoagulation (Coumadin) and hence the patient cannot have a contraindication to blood thinners. They have the best longevity (i.e. freedom from failure). Bioprosthetic valves (animal) do not require anticoagulation but have a lower longevity; they are used for young women who want to get pregnant, patients who do not want to be on blood thinners or patients who cannot take blood thinners (history of gastrointestinal or cerebral bleeding). A homograft refers to a valve taken from a human cadaver. Homografts do not require anticoagulation and seem to have good longevity. An autograft refers to the use of the patient's own pulmonary valve as an aortic valve replacement. The pulmonary valve is then replaced with a cadaveric homograft. This is called the Ross procedure. It is thought by some that the pulmonary valve in the aortic

position will last longer than a cadaver homograft. To see some images of heart valve replacement, please go to External Links folder. Practice Exercise 7 Let's try coding a valve replacement. Assign CPT code(s) to the following case. Please pay close attention to the text that is highlighted. OPERATIVE REPORT Preoperative Diagnosis: Severe aortic insufficiency and stenosis. Postoperative Diagnosis: Same. Operation: Aortic valve replacement. Anesthesia: General endotracheal. Procedure: The patient was taken to the operating room and placed on the table in the supine position. He was prepped and draped in the usual sterile fashion. A standard midsternotomy incision was made from the manubrium sternum down to the xiphoid. The patient was placed on full cardiopulmonary bypass. The standard oblique aortotomy incision was made in the proximal ascending aorta. Retraction sutures were placed, and the aortic valve apparatus was inspected. This revealed severely calcified bicuspid aortic valve structure. The right and left aortic cuffs were diffusely fused and there was heavy calcium going into the inferior mitral leaflet and also the ventricular septum. Diseased leaflets were resected sharply and diligent and careful decalcification of the annulus was performed, and the anterior mitral leaflet was also decalcified in addition to the ventricular septum. The left ventricular outflow tract was irrigated with cold saline solution to remove any particulate matter. Then, the aorta was measured with a St. Jude sizer. A 23 mm St. Jude mechanical aortic valve was elected for implantation. Then, 2-0 Tycron pledgeted valve sutures were passed through the annulus circumferentially and the pledgets positioned on the aortic side. Then, the other ends of the sutures were passed through the sewing ring of the 23 mm St. Jude mechanical aortic valve, and each suture individually ligated and cut. Valve sitting and function were satisfactory. The aortotomy was closed with a 4-0 Prolene running suture in two layers. Hemostasis was adequate. The patient was weaned from cardiopulmonary bypass without any difficulty. The

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sternum was closed with wires. The subcutaneous tissue was closed in two layers using 0 Vicryl running suture. The fascia at the lower end of the incision was closed with running 0 Vicryl sutures. The skin edges were approximated using subcuticular closure with 5-0 Vicryl sutures. No complications occurred during the procedure. The patient was taken to the recovery room in stable condition. How did you do? Check your answers . Please post any questions on the Discussion Board. .

CV Notes.htm

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