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Chapter 10: The Cardiovascular System

Terms in this set (25)

Where is the hypertension table located in ICD-10-CM?
Correct Answer: c.
There is no hypertension table in ICD-10-CM.
Response Feedback: Rationale: Hypertension is found in the ICD-10-CM Alphabetic Index by looking for Hypertension. Unlike ICD-9-CM, ICD-10-CM does not have a hypertension table.
A physician places a centrally inserted, tunneled central venous access device with a subcutaneous pump in a 7 year-old patient.
36563

Rationale: Look in the CPT® Index for Venous Access Device/Insertion/Central which directs the coder to 36560-36566. The code for insertion of a tunneled central venous access device with a subcutaneous pump is 36563.
How many layers of tissue does an artery have?
Three

Rationale: An artery has three layers: an outer layer of tissue, a muscular middle and an inner layer of epithelial cells
What is the term for the divider between the heart chamber walls?
Septum
Which main coronary artery bifurcates into two smaller ones?
Left

Rationale: The left main coronary artery branches into two slightly smaller arteries: the left anterior descending coronary artery and the left circumflex coronary artery.
Physician changes the old battery to a new one on a patient's dual chamber permanent pacemaker. What CPT® code(s) is/are reported?
33228

Rationale: CPT® guidelines state "When the battery of a pacemaker is changed, it is actually the pulse generator that is changed." It is reported with one code. In the CPT® Index look for Pacemaker, Heart/Replacement/Pulse Generator and you are referred to 33227-33229. Code 33228 is reported for dual chamber (dual lead system).
Procedure: Right femoral angiography, percutaneous transluminal tibioperoneal angioplasty and stenting.

Description of Procedure: The patient was premedicated and brought to the cardiovascular laboratory. The right inguinal region is prepped and draped in the usual sterile fashion. Local cutaneous anesthesia was obtained with 1% Lidocaine. A 6 French sheath was inserted antegrade into the right femoral artery. It was kinked and was replaced with a 6 French Arrow sheath.
Findings: Selective injections into the right femoral artery revealed diffuse irregularities of the superficial femoral artery with a 95 percent mid to distal stenosis and a 60 percent distal stenosis. The distal popliteal artery had an eccentric 60 percent stenosis. The tibial peroneal trunk was diffusely diseased with sequential 95 percent stenosis present. The anterior tibial and posterior tibial arteries are both occluded. We gave intravenous heparin 2,500 units. The distal vessel was wired with a V18 wire. We then dilated both superficial femoral artery lesions with a 5 x 4 Diamond balloon and achieved good angiographic result. We then elected to approach the tibial peroneal trunk that was a high-grade stenosis leading into the only remaining circulation. This was dilated with a 3 x 4 Diamond balloon. This had satisfactory results, but we elected to stent this for a better long term patency. We exchanged out the V18 wire for a coronary extra support wire and deployed a 3.5 x 40 mm GR2 coronary stent. This was then post-dilated to high pressures with a 3.5 x 40 mm NC Bandit balloon. We then performed inflations in the popliteal artery with a 4 x 2 Symmetry balloon, also achieving a satisfactory angiographic result. The balloon catheter was then withdrawn. The final angiographic result was excellent, with wide patency from the superficial femoral artery into the peroneal down to the ankle. Following the procedure, an ACT was obtained. The sheath was removed. A strong popliteal pulse was obtained. The patient was transported in stable condition to the recovery unit.

Impression:
1. Successful percutaneous transluminal angioplasty of sequential 95 and 60 percent mid and distal superficial femoral artery lesions.
2. Successful percutaneous transluminal angioplasty of a 60 percent popliteal lesion.
3. Successful percutaneous transluminal angioplasty of diffuse 95 percent tibial peroneal trunk stenosis with stenting producing a residual stenosis to 0 percent.
Which angioplasty codes are correct to report?
37130, 37225-51

Rationale: Treatment of lesions in the femoral popliteal artery and stenosis in the tibial peroneal trunk to restore blood supply (revascularization) using angioplasty with placement of a stent in the tibial peroneal trunk is being performed. 37224 is coded for the angioplasty in the femoral-popliteal artery. Look in the CPT® Index for Revascularization/Artery/Femoral-Popliteal, 37224-37227. Angioplasty was performed in the femoral artery and in the popliteal artery; therefore, the correct code is 37224. Look in the CPT® Index for Revascularization/Artery/Tibial/Peroneal which directs the coder to 37228-37235. Angioplasty and stent placement were performed; therefore, the correct code is 37230. Modifier 51 denotes additional procedures performed during the same session.
What information is needed in order to accurately code hypertension retinopathy in ICD-10-CM?
The affected eye(s)

Rationale: Hypertensive retinopathy for ICD-10-CM needs a 6th character that specifies the laterality of the retinopathy. Look in the ICD-10-CM Alphabetic Index for Retinopathy/hypertensive which directs you to H35.03.
What information is required to accurately code PVD with diabetes in ICD-10-CM?
Whether the patient has gangrene

Rationale: PVD is the abbreviation for Peripheral Vascular Disease. ICD-10-CM indexes PVD with diabetes with one code. For proper code selection the provider must document if the patient has gangrene or not. Look in the ICD-10-CM Alphabetic Index for Diabetes, diabetic/with/peripheral angiopathy which directs the coder to E11.51.
A patient presents to the hospital for a cardiovascular SPECT study. A single study is performed under stress, but without quantification, with a wall motion study, and ejection fraction. Select the CPT® code(s) for this procedure.
78451

Rationale: Code 78451 indicates a perfusion study either qualitative or quantitative. There is no mention of cardiac blood pooling imaging which eliminates choices a and b. Code 78453 reports a planar study, and this was a SPECT study, thus eliminating c. Look in the CPT® Index for Nuclear Medicine/Diagnostic/Heart/Myocardial Perfusion Imaging which directs you to 78451-78454 or SPECT/Heart/Single which directs you to 78451, 78453.
Patient is diagnosed with acute systolic heart failure due to hypertension with CKD stage 4.
I13.0, I50.21, N18.4

Rationale: There is a causal connection with hypertension and heart failure, and one is assumed with CKD, so combination code I13.0 is required. The type of heart failure and stage of CKD are also needed to complete the coding. In the ICD-10-CM Alphabetic Index look for Hypertension/cardiorenal (disease)/with heart failure/with stage 1 through stage 4 chronic kidney disease which directs you to I13.0. In the Tabular List there is a note below I13.0 to use additional code to identify the type of heart failure. Look in the Alphabetic Index for Failure/heart/systolic (congestive)/acute referring you to I50.21. Instructions further indicate to also code for the stage 4 chronic kidney disease. Look in the Alphabetic Index for Disease, diseased/kidney/chronic/stage 4 (severe) which directs the coder to N18.4. Verify code selection in the Tabular List.
A physician supervises a patient during a cardiac stress test performed at the hospital and writes the interpretation and report. Which code(s) is/are reported for the physician NOT employed by the hospital?
93016, 93018

Rationale: The physician performed both professional components of the stress test in the hospital setting. Look in the CPT® Index for Stress Tests/Cardiovascular and you are referred to 93015-93024. Modifier 26 is not required because these services are professional services.
In the cath lab a physician places a catheter in the aortic arch from a right femoral artery puncture to perform an angiography. Fluoroscopic imaging is performed by the physician. What CPT® code(s) is/are reported?
36221

Rationale: The aorta is the trunk of the system, so this is a non-selective catheterization. Look in the CPT® Index for Angiography/Cervicocerebral Arch. Only one code is reported for the catheterization and fluoroscopic imaging which is code 36221.
A PICC with a port is placed under fluoroscopic guidance for a 45 year-old patient for chemotherapy infusion by a physician. The procedure was performed in the hospital. Report the codes for the physician.
36571, 77001-26

Rationale: Look in the CPT® Index for Central Venous Catheter Placement/Insertion/Peripheral/with Port and you are referred to 36570-36571. The age of patient is 45; therefore, report 36571. Fluoroscopic guidance for central venous access is reported with 77001 and can be found by looking in the CPT® Index for Fluoroscopy/Venous Access Device directing you to 36598, 77001. The correct code for fluoroscopy is 77001. Modifier 26 is necessary to show the professional service only.
In the cath lab, from a right femoral artery access, the following procedures are performed: Catheter placed in the left renal, accessory renal superior to the left renal and one main right renal artery. Radiologic supervision and imaging is performed in all locations. What CPT® code(s) is/are reported?
36252

Rationale: Look in the CPT® Index for Angiography/Renal Artery and you are directed to 36251-36254. This is a bilateral procedure, with an accessory left renal artery. Code 36252 includes bilateral and accessory renal angiography, and radiologic supervision and imaging.
CLINICAL SUMMARY: The patient is a 55 year-old female with known coronary disease and previous left anterior descending and diagonal artery intervention, with recent recurrent chest pain. Cardiac catheterization demonstrated continued patency of the stented segment, but diffuse borderline changes in the ostial/proximal portion of the right coronary artery.

PROCEDURE: With informed consent obtained, the patient was prepped and draped in the usual sterile fashion. With the right groin area infiltrated with 2percent Xylocaine and the patient given 2 mg of Versed and 50 mcg of fentanyl intravenously for conscious sedation and pain control, the 6 French catheter sheath from the diagnostic study was exchanged for a 6 French sheath and a 6 French JR4 catheter with side holes utilized. The patient initially received 3000 units of IV heparin, and then IVUS interrogation was carried out using an Atlantis Boston Scientific probe. After it had been determined that there was significant stenosis in the ostial/proximal segment of the right coronary artery, the patient received an additional 3000 units of IV heparin, as well as Integrilin per double bolus injection. A 3.0 16-mm-long Taxus stent was then deployed in the ostium and proximal segment of the right coronary artery in a primary stenting procedure with inflation pressure up to 12 atmospheres applied. Final angiographic documentation was carried out, and then the guiding catheter pulled, the sheath upgraded to a 7 French system, because of some diffuse oozing around the 6 French sized sheath, and the patient is now being transferred to telemetry for post-coronary intervention observation and care.

RESULTS: The initial guiding picture of the right coronary artery demonstrates the right coronary artery to be dominant in distribution, with luminal irregularities in its proximal and mid-third with up to 50 percent stenosis in the ostial/proximal segment per angiographic criteria although some additional increased radiolucency observed in that segment.

IVUS interrogation confirms severe, concentric plaque formation in this ostial/proximal portion of the right coronary artery with over 80 percent area stenosis demonstrated. The mid, distal lesions are not significant, with less than 40 percent stenosis per IVUS evaluation.
Following the coronary intervention with stent placement, there is marked increase in the ostial/proximal right coronary artery size, with no evidence for intimal disruption, no intraluminal filling defect, and TIMI III flow preserved.

CONCLUSION: Successful coronary intervention with drug eluting Taxus stent placement to the ostial/proximal right coronary artery.
92928-RC, 92978

Rationale: IVUS is the abbreviation for Intravascular Ultrasound. Stent placement (92928) and IVUS (92978) are reportable. To find the stent placement code look in the CPT® Index for Coronary Artery/Angioplasty/with Stent Placement which directs you to 92928-92929. Modifier 51 is not appended to IVUS as it is an add-on code. IVUS is reported for each vessel when performed in multiple vessels. Modifier RC is appended to 92928 to indicate the right coronary artery. The coronary artery modifiers are only used for coronary artery interventions. To locate IVUS look in the CPT® Index for Vascular Procedures/Intravascular Ultrasound/Coronary Vessels which directs you to 92978-92979. Do not append modifier RC to the IVUS code.
MAZE procedure is performed on a patient with atrial fibrillation. The physician isolates and ablates the electric paths of the pulmonary veins in the left atrium, the right atrium and the atrioventricular annulus while on cardiopulmonary bypass.
33256

Rationale: The procedure described above is extensive according to CPT® definition. Look in the CPT® Index for Maze Procedure/Open and you are referred to 33254-33256. The patient was on bypass; therefore, the correct code is 33256
`PREOPERATIVE DIAGNOSIS: Heart Block
POSTOPERATIVE DIAGNOSIS: Heart Block
ANESTHESIA: Local anesthesia
NAME OF PROCEDURE: Reimplantation of dual chamber pacemaker
DESCRIPTION: The chest was prepped with Betadine and draped in the usual sterile fashion. Local anesthesia was obtained by infiltration of 1% Xylocaine. A subfascial incision was made about 2.5 cm below the clavicle, and the old pulse generator was removed. Using the Seldinger technique, the subclavian vein was cannulated and through this, the old atrial lead was removed, and a new atrial lead (serial # 6662458) was placed in the right atrium and to the atrial septum. Thresholds were obtained as follows: The P-wave was 1.4 millivolts, atrial threshold was 1.6 millivolts with a resultant current of 3.5 mA and resistance of 467 ohms.
Using a second subclavian stick in the Seldinger technique, the old ventricular lead was removed and a new ventricular lead (serial # 52236984) was inserted and placed into the right ventricular apex. The thresholds were obtained and were as follows: R-wave was 23.5 millivolts. The patient was pacing at 100% at 0.5 volts, with resultant current of 0.8 mA and resistance of 480 ohms. When we were satisfied with the thresholds, the leads were connected to the pacemaker generator (serial # 22561587), which was inserted into the previously created pocket.
The wound was thoroughly irrigated with antibiotic solution and hemostasis was obtained. The incision was closed in layered fashion with 2-0 Dexon. A compressive dressing was applied, and the patient tolerated the procedure very well. He was taken to the recovery room in satisfactory condition.
33235, 33208-51, 33233-51

Rationale: Code 33235 reports removal of the electrodes of a dual pacemaker lead system. Code 33208 reports replacement of permanent pacemaker generator with transvenous electrodes to the right atrium and right ventricle, and 33233 reports the removal of a pacemaker generator. Modifier 51 reports multiple procedures performed during the same session. Look in the CPT® Index for Pacemaker, Heart/Insertion which direct you to 33206-33208. Next look for Pacemaker, Heart/Removal/Pulse Generator Only which directs you to 33233. Look for Pacemaker, Heart /Removal/Transvenous Electrodes which directs the coder to 33234-33235.
In the cardiac suite, an electrophysiologist performs an EP study. With programmed electrical stimulation, the heart is stimulated to induce arrhythmia. Observed is right atrial and ventricular pacing, recording of the bundle of His, right atrial and ventricular recording and left atrial and ventricular pacing and recording from the left atrium.
93620, 93621, 93622

Rationale: The studies performed make up a comprehensive study (93620) which includes: evaluation with right atrial pacing and recording, right ventricular pacing and recording, and His bundle recording with induction of or attempted induction of arrhythmia. Left atrial pacing and recording (93621) and left ventricular pacing and recording (93622) are add-on codes. Look in the CPT® Index for Electrophysiology Procedure which directs you to 93600-93660.
Patient undergoes a mitral valve repair with a ring insertion and an aortic valve replacement, on cardiopulmonary bypass. Which are the correct CPT® codes?
33416, 33405-51

Rationale: 33426 reports mitral valve valvuloplasty with a prosthetic ring, and 33405 reports an aortic valve replacement with cardiopulmonary bypass. Modifier 51 is required on the second procedure to indicate multiple procedures performed during the same setting. Look in the CPT® Index for Valvuloplasty/Mitral Valve or Mitral Valve/Repair and you are referred to 33425-33427. Look in the in the CPT® Index for Replacement/Aortic Valve. You must examine the range of codes given for this procedure.
What is included in all vascular injection procedures?
Necessary local anesthesia, introduction of needles or catheters, injection of contrast media with or without automatic power injection and/or necessary pre-and post-injection care specifically related to the injection procedure.

Rationale: CPT® guidelines for Vascular Injection Procedures indicate the above listed in D as being included.
CLINICAL SUMMARY: The patient is a 41 year-old female with known coronary disease and recent recurrent chest pain, cardiac catheterization demonstrated subtotal occlusion of the diagonal artery at its takeoff from the left anterior descending artery.

PROCEDURE: With informed consent obtained, the patient was prepped and draped in the usual sterile fashion. With the right groin area infiltrated with 2% Xylocaine, the patient was given 2 mg of Versed and 50 mcg Fentanyl intravenously for conscious sedation and pain control. The right femoral artery was cannulated with a modified Seldinger technique and a 6 French catheter sheath placed. A 6 French JL3.5 catheter with no side holes was utilized as a guiding catheter. After the initial guiding picture had been obtained, the patient was given Angiomax per protocol, and a short Cross-it 100 wire was advanced to the LAD and then into the diagonal vessel. A 2.0. 15-mm-long Maverick balloon was used for dilatation of the diagonal artery ostium with inflation pressure up to 8 atmospheres applied. Final angiographic documentation was carried out after the patient received 200 mcg of intracoronary nitroglycerine. The guiding catheter was then pulled, the sheath secured in place. The patient is now being transferred to telemetry for post coronary intervention observation and care.

RESULTS: The initial guiding picture of the left coronary system demonstrates the high-grade ostial stenosis of the diagonal artery taking off within the LAD. Following the coronary intervention with balloon angioplasty there is complete resolution of the stenosis with less than 10 percent residual narrowing observed, no evidence for intimal disruption, no intraluminal filling defect, and good antegrade TIMI III flow preserved.

CONCLUSION: Successful coronary intervention with balloon angioplasty to the ostial/proximal segment of the second diagonal vessel.
92920-LD

Rationale: Percutaneous balloon angioplasty (Maverick balloon used for dilatation) performed in the diagonal artery of the left anterior descending coronary artery (LD). A base code for angioplasty of a major coronary artery or branch is reported. Look in the CPT® Index for Coronary Artery/Angioplasty which directs you to 92920-92921. The angioplasty 92920 is reported with modifier LD. Conscious sedation is included in the procedure.
Preoperative Diagnosis: Coronary artery disease associated with congestive heart failure. In addition, the patient has diabetes and massive obesity.
Postoperative Diagnosis: Same
Anesthesia: General endotracheal
Incision: Median sternotomy

Indications: The patient had presented with severe congestive heart failure associated with her severe diabetes. She had significant coronary artery disease, consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system.

She also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to her right system. The decision was therefore made to perform a coronary artery bypass grafting procedure particularly because she is so symptomatic. The patient was brought to the operating room.

Description of Procedure: The patient was brought to the operating room and placed in supine position. Myself, the operating surgeon was scrubbed throughout the entire operation. After the patient was prepared, median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh. The patient weighs almost three hundred pounds and with her obesity there was some concern as to taking down the left internal mammary artery. Because the radial artery appeared to be a good conduit, she should have an arterial graft to the left anterior descending artery territory. She was cannulated after the aorta and atrium were exposed and after full heparinization.

Attention was turned to the coronary arteries. The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow. Proximal anastomosis was then carried out to the foot of the aorta. The left anterior descending artery does not have severe disease but is also a very good target, and the radial artery was anastomosed to this target, and the proximal anastomosis was then carried out to the root of the aorta.

Sternal closure was then done using wires. The subcutaneous layers were closed using Vicryl suture. The skin was approximated using staples.
33533, 33517, 35600

Rationale: One arterial graft and one vein graft was performed. Look in the CPT® Index for Coronary Artery Bypass Graft (CABG)/Arterial-Venous Bypass for range 33517-33519. Then look for Arterial Bypass which directs you to 33533-33536. This was a combination arterial-venous graft with one vein graft (33517) and one an arterial graft (33533). The upper extremity radial artery graft procurement (35600) is separately reportable. Codes 33517 and 35600 are add-on codes and are modifier 51 exempt.
A patient has a complete TTE performed to assess her mitral valve prolapse (congenital). The physician performs the study in his cardiac clinic. Which is the correct CPT® is reported?
93303

Rationale: Patient has a congenital cardiac anomaly. The procedure was performed in the physician's clinic; therefore, the global service is reported which means no modifier is necessary. Look in the CPT® Index for Echocardiography/Congenital Cardiac Anomaly/Transthoracic and you are referred to 93303-93304.
In the hospital setting a patient undergoes transcatheter placement of an extracranial vertebral artery stent in the right vertebral artery. Which CPT® code is reported by the physician providing only the radiologic supervision and interpretation?
0075T-26

Rationale: This is a Category III code. Look in the CPT® Index for Stent/Placement/Transcatheter/Intravascular/Extracranial and you are referred to 0075T-0076T. When you check these codes you see supervision and interpretation is included; therefore, modifier 26 reports the professional service.
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