may 2019 lunch and learn · •pacemakers vs. internal cardiac defibrillators (icds) insertions ......

May 2019 Lunch and Learn

Coding and Documenting Cardiovascular Procedures for Accurate CPT and ICD-10-PCS Code Assignment

Objectives

After completing this education participants will:

• Have refreshed their knowledge and understanding of the anatomy and physiology of the circulatory system

• Have a better understanding of how to assign CPT and ICD-10-PCS codes the following procedures:• Pacemakers vs. Internal Cardiac Defibrillators (ICDs) Insertions• Percutaneous Transluminal Cardiac Angioplasty (PTCA)• Cardiac Bypass

Anatomy and Physiology –Circulatory

Anatomy of Heart

Heart Valves and Chambers

Insertion of Pacemakers and ICDs

Pacemaker

•Putting in a non-biological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part.

•Sole objective is to put in a device without doing anything else to the body part.

ICD-10-PCS Root Operation - Insertion (H)

CPT - Pacemaker and Defibrillator

Coding Scenario

The patient undergoes a placement of a dual chamber pacemaker for treatment of symptomatic sick sinus syndrome. The chest was prepped and draped in the usual fashion the left chest was infiltrated with 1% lidocaine. An incision was made deltopectoral groove on the left side. This was also carried down to the superficial fascia of the pectoral muscle using sharp dissection and Bovie. A pocket was made over the left pectoral muscle for the placement of the generator. There was good hemostasis. The pocket was irrigated copiously with antibiotic solution containing cefazolin and amikacin. The generator was placed in the subcutaneous pocket and the incision was closed. Both the right atrial and right ventricle lead were placed percutaneously.

What section(s) are involved?• Code 1, 2 and 3 - Medical and Surgical

What body system are involved?• Code 1 - Subcutaneous Tissue and Fascia• Code 1 and 2 - Heart and Great Vessels

What are the root operations(s)?• Code 1, 2, and 3 - Insertion

What are the body part(s)? • Code 1 - Subcutaneous Tissue and Fascia, Chest• Code 2 - Atrium, Right• Code 3 - Ventricle, Right

What is the approach? • Code 1 - Open• Code 2 and 3 - Percutaneous

Does the procedure involve a device? • Code 1 - Pacemaker, Dual Chamber• Code 2 and 3 - Cardiac Lead, Pacemaker

What is the qualifier? • Code 1, 2, and 3 - No Qualifier

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Question to ask when building the code(s):

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Approach Decision Tree

Start Incision Open

Through Skin?

Through Opening?

Through Scope?

Percutaneous Endoscopic

Percutaneous

External

Through Scope?

Percutaneous Endoscopic Assistance?

Via Natural or Artificial Opening


with Percutaneous Endoscopic Assistance


Endoscopic

Yes

No

No

No

Yes Yes

Yes

Yes Yes

No

No

No

ICD-10-PCS - Placement of Battery/Generator

0JH606Z

ICD-10-PCS - Placement Right Atrial Cardiac Lead, Pacemaker

02H63JZ

ICD-10-PCS - Placement Right Ventricle Cardiac Lead, Pacemaker

02HK3JZ

CPT – Dual Chamber Pacemaker

33208

Defibrillator

Placement of Defibrillator Generator into Chest

0JH608Z

Insertion of Defibrillator Lead into Right Atrium

02H63JZ

Percutaneous Transluminal Angioplasty (PTCA)

Root Operation - Dilation

• Expanding an orifice or the lumen of a tubular body part.

• The orifice may be natural, or an artificially created orifice.

• Objective of the procedure is to enlarge the diameter of a tubular body part or orifice.

• Methods include both intraluminal (within) and extraluminal (without).

• A device placed to maintain the new diameter is an integral part of the dilation procedure, and is coded to a sixth-character value in the procedure code.

Coding Scenario

The patient was admitted with recurrent unstable angina that could not be controlled with sublingual nitroglycerine. There was no history of bypass or angioplasty in the past. On this visit a left cardiac catheterization with multiple coronary arteriography with low osmolar contrast was performed, a narrowing in the left anterior descending coronary artery and a stenotic area in an intermediate branch were identified. A percutaneous transluminal coronary angioplasty (PTCA) was performed on both vessels.

What is the section?Code 1 – Medical and SurgicalCode 2 – Measurement and MonitoringCode 3 – ImagingWhat body system are involved?• Code 1 – Heart and Great Vessels• Code 2 – Physiological System• Code 3 – HeartWhat are the root operations(s)?• Code 1 – Dilation• Code 2 – Measurement• Code 3 – Fluoroscopy

What are the body part(s)? • Code 1 – Coronary Artery, Two Sites• Code 2 – Cardiac• Code 3 – Coronary Arteries, MultipleWhat is the approach and contrast? • Code 1 and 2 – Percutaneous• Code 3 – Low OsmolarDoes the procedure involve a device and function? • Code 1 – No Device• Code 2 – Sample and Pressure• NoneWhat is the qualifier? • Code 1 – No Qualifier• Code 2 – Left Heart• Code 3 – None

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Start Incision Open

Through Skin?

Through Opening?

Through Scope?


Percutaneous

External

Through Scope?






Endoscopic

Yes

No

No

No

Yes Yes

Yes

Yes Yes

No

No

No

Procedure: Percutaneous transluminal coronary angioplasty

Step 1 Go to the alphabetic index of PCS and look up the main term and subterm(s)

Dilation; Artery; Coronary; Two Sites (0271)

Step 2 Go the (0271) table and build the code

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ICD-10-PCS - Coding Scenario

ICD-10- PCS - Coding Scenario

02713ZZ

Procedure: Cardiac Catheterization


Measurement; Cardiac; Sampling and Pressure; Left Heart (4A02)

Step 2 Go the (4A02) table and build the code

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4A023N7

Procedure: Coronary arteriography with contrast


Arteriography; -- see Fluoroscopy, Heart (B21)

Step 2 Go the (B21) table and build the code

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B2111ZZ

CPT Codes – Coding Scenario

92920 - LD


93458 - 59


92921 - LD

Coronary Artery Bypass

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Coronary Artery Bypass Graft

B3.6c. If multiple coronary artery sites are bypassed, a separate procedure is coded for each coronary artery site that uses a different device and/or qualifier.

Example: Aorta-coronary artery bypass and internal mammary coronary artery bypass are coded separately.

B3.9. If an auto graft is obtained from a different body part in order to complete the objective of the procedure, a separate procedure is coded.

Example: Coronary bypass with excision of saphenous vein graft, excision of saphenous vein is coded separately.

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Bypass Procedures Guidelines

Coding Clinic: Aortocoronary Bypass Graft Utilizing Y-GraftCoding Clinic, First Quarter 2016: Page 27 Question: A patient with multi-vessel coronary artery disease was placed on cardiopulmonary bypass and underwent quadruple aortocoronary artery bypass• Using the left internal mammary artery (LIMA) to the left anterior descending (LAD)• The left greater saphenous vein was harvested endoscopically.• Saphenous vein graft (SVG) to right posterior descending artery (RPDA), obtuse marginal (OM), and diagonal 1

(D1), utilizing Y graft.

Answer:02100Z9 Bypass Coronary Artery, One Artery from Left Internal Mammary, Open Approach021209W Bypass Coronary Artery, Three Arteries from Aorta with Autologous Venous Tissue, Open Approach06BQ4ZZ Excision of Left Saphenous Vein, Percutaneous Endoscopic Approach5A1221Z Performance of Cardiac Output, Continuous

Coding ScenarioA patient who has had recurrent attacks of angina presented to the emergency department because he felt the angina attacks were getting worse. He was admitted to the hospital for diagnostic studies to determine the underlying cause of this unstable angina. The physician performs combined right and left heart catheterization, which revealed significant atherosclerotic heart disease. During left heart catheterization, a flexible catheter is advanced through femoral/brachial artery to the aortic arch till coronary artery ostium under fluoroscopic guidance. Intraprocedural injection of contrast/dye is performed to check for catheter position. Coronary injections are performed for the assessment of stenosis/coronary artery disease. The catheter is also used to pass the aortic valve till left ventricle to measure left ventricular pressure (for the assessment of ventricular function). During right heart catheterization, the catheter is advanced to the pulmonary artery through the right atrium and ventricle by using swan ganz catheter (inserted through the femoral or brachial vein). X Ray images facilitate the catheter placement throughout the procedure.

He was advised that coronary artery bypass surgery was indicated. The following day the patient presented to the surgical suite. The right greater saphenous vein was harvested. Reversed right greater saphenous vein grafts were brought from the aorta to the obtuse marginal and the right coronary arteries; the left internal mammary artery was loosened and brought down to the left anterior descending artery to bypass this obstruction. Extracorporeal circulation (continuous cardiac output) and an intraoperative pacemaker were used during the procedure.

What is the section?Code 1, 2, and 3 – Medical and SurgicalCode 4 – Extracorporeal or Systemic AssistanceCode 5 –Measurement and MonitoringWhat body system are involved?• Code 1 and 2 – Heart and Great Vessels• Code 3 – Lower Veins• Code 4 and 5 – Physiological SystemWhat are the root operations(s)?• Code 1 and 2 – Bypass• Code 3 – Excision• Code 4 – Performance• Code 5 - MeasurementWhat are the body part(s)? • Code 1 – Coronary Artery, Two Arteries (Free Graft)• Code 2 – Coronary Artery, One Artery (pedicle Graft)• Code 3 – Saphenous Vein, Right• Code 4 and 5- Cardiac

What is the approach and duration? • Code 1, 2, 3 – Open• Code 4 – Continuous• Code 5 - PercutaneousDoes the procedure involve a device and function? • Code 1 – Autologous Venous Tissue • Code 2 and 3 – No Device• Code 4 – Output• Code 5 - Sample and PressureWhat is the qualifier? • Code 1 – Aorta• Code 2 – Internal Mammary, Left• Code 3, 4 – No Qualifier• Code 5 – Bilateral

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Start Incision Open

Through Skin?

Through Opening?

Through Scope?


Percutaneous

External

Through Scope?






Endoscopic

Yes

No

No

No

Yes Yes

Yes

Yes Yes

No

No

No

ICD-10-PCS - Bypass Two Sites – (Saphenous Vein)Obtuse Marginal and Right Coronary

Procedure: Bypass of the left anterior descending and obtuse marginal


Bypass; Artery; Coronary; Two Site (0211)


ICD-10-PCS - Bypass Two Sites – (Saphenous Vein)Obtuse Marginal and Right Coronary

021109W

CPT - Bypass Two Sites – (Saphenous Vein)Obtuse Marginal and Right Coronary

33518

ICD-10-PCS - Bypass - Left Anterior Descending Artery with the Left Internal Mammary

Procedure: Bypass of the left anterior descending artery with the left internal mammary


Bypass; Artery; Coronary; One Site (0210)


ICD-10-PCS - Bypass - Left Anterior Descending Artery with the Left Internal Mammary

02100Z9

CPT- Bypass - Left Anterior Descending Artery with the Left Internal Mammary

33533

ICD-10-PCS - Harvesting of Right Greater Saphenous Vein

Procedure: Excision of the saphenous vein


Excision; Vein; Greater Saphenous; Right (06BP)

Step 2 Go the (06BP) table and build the code

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ICD-10-PCS - Harvesting of Right Greater Saphenous Vein

06BP0ZZ

CPT - Harvesting of Right Greater Saphenous Vein

ICD-10-PCS - Cardiopulmonary Bypass

Procedure: Cardiopulmonary Bypass


Performance; Cardiac; Continuous; Output (5A1221Z)

Step 2 Go the (5A1221Z) table and verify the code

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ICD-10-PCS - Cardiopulmonary Bypass

5A1221Z

ICD-10-PCS - Combined Left & Right Heart Catheterization

Procedure: Combined left and right heart catheterization


Measurement; Cardiac; Sampling and Pressure; Bilateral (4A02)

Step 2 Go the (4A02) table and build the code

ICD-10-PCS - Combined Left & Right Heart Catheterization

4A023N8

CPT - Combined Left & Right Heart Catheterization

93453

Thank YouFor Your Time and Attention!

Reference

Brown, Faye. ICD-9-CM Coding Handbook, 2014, Revised Edition, Revised by Nelly Leon-Chism, RHIA. Health Forum, Inc. Electronic version.

CPMC Heart & Vascular Center. "How is the heart supposed to work?." Electrical regulation of the heart. CPMC, 2011. Web. Aug. 2011.

<http://www.cpmc.org/services/heart/conditions/afheartworks/.html>.

Detailed Instructions for Appropriate ICD-10-CM Coding. (2012). West Valley City, UT: OptumInsight.

Frazier, M. S., & Drzymkowski, J. W. (2008). Essential of Human Disease and Conditions.St. Louis, MO: Elsevier.

may 2019 lunch and learn · •pacemakers vs. internal cardiac defibrillators (icds) insertions ......

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