cardiologist list

Cardiovascular System

Chapter Topics
Coding Highlights
Cardiovascular Coding in the Surgery Section
Cardiovascular Coding in the Medicine Section
Cardiovascular Coding in the Radiology Section

Learning Objectives
After completing this chapter you should be able to
1

Understand cardiovascular services reported with codes from the Surgery, Medicine, and Radiology sections
2
Review cardiovascular coding terminology
3
Recognize the major differences in the subheadings of the
Cardiovascular subsection
4
Define rules of coding cardiovascular services when using codes from the Medicine section
5
Identify the major rules of coding cardiovascular services using the Radiology section codes
6
Demonstrate ability to code Cardiovascular services
CODING HIGHLIGHTS
Cardiology is one of the largest subspecialties in medicine, and numerous modern techniques are used to diagnose and treat cardiac conditions
A cardiologist is an internal medicine physician who is specialized in the diagnosis and treatment of conditions of the heart
A cardiologist can further specialize in cardiovascular surgical procedures or other treatment and diagnostic specialties
In a smaller practice a cardiologist may do many of these procedures himself/herself, whereas in a larger practice a cardiologist may be more specialized and provide a more limited number of services
Coding from Three Sections
When you are reporting cardiology services you will often be using codes from three sections: Surgery, Medicine, and Radiology
n
The Surgery section contains codes for cardiovascular surgical procedures
n
The Medicine section contains codes for nonsurgical cardiovascular services
n
The Radiology section contains diagnostic studies or radiologic visualization codes
21-1 is a list of the section information that is most often used when reporting cardiovascular services
The confusion in coding cardiology usually comes from not understanding the components (parts) of coding cardiovascular services, the various locations of these codes in the CPT manual, and the terminology associated with cardiovascular services
To clarify cardiology coding, let’s begin by reviewing the definitions of invasive, noninvasive, electrophysiology, and angiography as they relate to cardiovascular coding
Invasive
Invasive is entering the body—breaking the skin—to make a correction or for examination
An example of an invasive cardiac procedure is the removal of a tumor from the heart
The chest is opened, the ribs spread apart, the heart fully exposed to the view of the surgeon, and the tumor removed
Another example is the removal of a clot from a vessel
The surgeon usually enters the body percutaneously (through the skin) by means of a catheter that is threaded through the vessel to the location of the clot
The clot can then be pulled out of the vessel through the catheter or can be injected with a substance that dissolves it
Although an open surgical procedure was not used, the body was entered—an invasive procedure
Invasive cardiology procedures are also called interventional procedures
some codes are located in the Surgery section for the surgical technique, and others are located in the Medicine section and the Radiology section for the radiologic supervision and guidance, and both codes are reported for the one procedure
Sometimes, one physician provides both components of the procedure and in other instances, two physicians will provide the components

SURGERY SECTION

Cardiovascular System (33010-37799)

Heart and Pericardium
Endoscopy
Arteries and Veins
Adjuvant TechniquesMEDICINE SECTION

Cardiovascular System (92920-93799)
Therapeutic Services and Procedures
Cardiography
Implantable and Wearable Cardiac Device
Evaluations
Echocardiography
Cardiac Catheterization
Intracardiac Electrophysiological Procedures
Peripheral Arterial Disease Rehabilitation
Noninvasive Physiologic Studies and Procedures
Other Procedures

RADIOLOGY SECTION

Diagnostic Radiology (75557-75791)
Heart
Vascular Procedures
Aorta and Arteries
Diagnostic Ultrasound (various)
Ultrasonic Guidance Procedures
Radiologic Guidance (77001-77032)
Nuclear Medicine (78414-78499)
Cardiovascular System

Noninvasive
Noninvasive services and procedures—not breaking the skin—are usually performed for diagnostic purposes

Usually, performing these procedures does not require entering the body
rather, they are diagnostic tests that can be performed from outside the body, for example, echocardiography (93303- 93352) or cardiography (93000-93278) from the Medicine section
From the Trenches
What qualities best describe a medical coder?
“Detail oriented, investigative and research oriented, patient, and excellent analytical skills

CODING SHOT
To choose the correct cardiology code, first determine whether the procedure or service was invasive (interventional [percutaneous] or open) or noninvasive

Electrophysiology
Electrophysiology (EP) is the study of the electrical system of the heart and includes the study of arrhythmias
Diagnostic procedures include procedures such as recordings from inside the heart by placing wire electrodes into the heart percutaneously and by means of an electrogram, recording the electrical activity within the heart
The codes for these invasive diagnostic and therapeutic procedures are located in the Medicine section (93600-93662)
As a treatment for abnormal electrical activity in the heart, more invasive treatments can be performed, such as the placement of a pacemaker, cardioverter-defibrillator, or other devices to regulate the rhythm of the heart
These invasive treatments are surgical procedures, and the codes are located in the Surgery section, Cardiology subsection, Pacemaker or Pacing Cardioverter- Defibrillator (33202-33249)
There are also Surgery codes for operative procedures to correct electrophysiologic problems of the heart (33250-33266), when the electrical problems are corrected surgically by incision, excision, or ablation
For example, code 33250 reports an operative ablation performed for patients with conduction disorders such as Wolff-Parkinson-White syndrome, in which there is a short circuit between the atria and ventricles
This is a congenital defect that results in rapid heartbeats due to a muscle fiber that remains after the heart developed
This fiber would usually not be present
in the normally developed heart and when it is present it interrupts normal conduction
The surgeon ablates the fibers by means of a small wire that destroys the fibers and restores normal heart rhythm
You will be learning more about the electrical conduction system of the heart later in this chapter
Angiography
Nuclear cardiology is a diagnostic specialty that plays a very important role in modern cardiology
A physician who specializes in nuclear cardiology uses radioactive radiologic procedures to aid in the diagnosis of cardiologic conditions
When reporting nuclear cardiology services, HCPCS Level II codes will often also be reported
For example, “A” codes report radiopharmaceuticals
“G” codes report the procedures and procedures combined with the supplies, radiopharmaceuticals, and drugs
“J” codes report the drugs
and “Q” codes report contrast agents
For example, if the cardiologist provided a myocardial perfusion imaging, tomography (SPECT) (78452) during a stress test (93015) with two units A9500 (99mTc sestambi, per study dose) and 60 mg of adenosine (J0152), you would report: 78452, 93015, A9500 3 2, and J0152 3 2
Now that you are familiar with some of the basic terms and coding of the cardiovascular services and procedures, let’s look at the three sections where you will locate the components (parts) of cardiovascular coding: Surgery, Medicine, and Radiology
CARDIOVASCULAR CODING IN THE SURGERY SECTION
The Cardiovascular System subsection (33010-37799) of the Surgery section contains diagnostic and therapeutic procedure codes that are divided on the basis of whether the procedure was performed on the heart/pericardium or on arteries/veins
The Heart and Pericardium subheading (33010-33999) contains codes for procedures that involve the repair of the heart and coronary vessels, such as placement of pacemakers, repair of valve disorders, and graft/bypass procedures
In the Arteries and Veins subheading (34001-37799) are the same types of procedures but for noncoronary (nonheart) vessels
For example, a thromboendarterectomy is the removal of a thrombus (stationary obstruction) and a portion of the lining of an artery
When a thromboendarterectomy is performed on a coronary artery, you would assign a code from the Heart and Pericardium subheading
but if the procedure was performed on a noncoronary artery, you would assign a code from the Arteries and Veins subheading
CODING SHOT
The location of the procedure—coronary or noncoronary—is the first step in selecting the correct cardiovascular surgical code, because the CPT codes are divided on the basis of whether a procedure involved coronary or noncoronary vessels
Heart and Pericardium
The Surgery section, Cardiovascular System subsection, Heart and Pericardium subheading (33010-33999) contains procedures that are performed both percutaneously and through open surgical sites
There are always many revisions and additions in this subheading each year to reflect the many advances in this important specialty
Numerous notes are located throughout the subheading, and they must be read prior to coding
Codes in the Heart and Pericardium subheading are for services provided to repair the heart (Fig
21-2), pericardiocentesis, or coronary vessels (Fig
21-3)
Pericardiocentesis codes 33010 and 33011 are divided based on initial or subsequent service
FIGURE Internal view of heart
Brachiocephalic artery
Superior vena cava
Pulmonary artery
Right pulmonary vein
Right atrium
Pulmonary semilunar valve
Tricuspid valve
Right ventricle
Inferior vena cava
Left common carotid artery
Left subclavian artery
Arch of aorta
Pulmonary artery
Pulmonic vein
Left atrium
Aortic valve
Mitral (bicuspid) valve
Left ventricle
Myocardium
Epicardium
Endocardium
Interventricular septum
Aorta
ApexFIGURE External view of heart

Brachiocephalic trunk
Superior vena cava
Right atrium
Right coronary artery
Left common carotid artery
Left subclavian artery
Arch of aorta
Pulmonary trunk
Left atrium
Left coronary artery
Circumflex branch of left coronary artery
Anterior descending branch of left coronary artery in interventricular sulcus
Posterior descending branch of left coronary artery

Pericardium
Pericardiocentesis (33010, 33011) is a procedure in which the surgeon withdraws fluid from the pericardial space by means of a needle inserted percutaneously into the space as illustrated in Fig

21-4
The insertion can be performed using radiologic (ultrasound) guidance—the use of which would be reported with a separate code from the Radiology section
There is a note following the pericardiocentesis codes that states: “(For radiological supervision and interpretation, use 76930)”
that is, ultrasonic guidance for pericardiocentesis, imaging supervision, and interpretation
Watch for these directional features throughout the Cardiovascular System subsection
The fluid withdrawn during a pericardiocentesis is then examined for microbial agents (such as tuberculosis), neoplasia, or autoimmune diseases (such as lupus or rheumatoid arthritis)
The pericardiocentesis codes are divided on the basis of whether the service was initial or subsequent
A tube pericardiostomy (33015) uses the same procedure described above, but a catheter is left in the pericardial sac/space leading to the outside of the body to allow for continued drainage
The remaining procedures in the Pericardium category (33020-33050) are open surgical procedures for the removal of clots, foreign bodies, tumors, cysts, or a portion of the pericardium to create a window to allow pericardial fluid to drain into the pleural space
Cardiac Tumor
A procedure performed to remove a tumor of the pericardium is reported using a code from the Pericardium category (33010-33050), but if a tumor is removed from the heart, you would select a code from the category Cardiac Tumor (33120, 33130)
There are only two tumor-removal codes in the Cardiac Tumor category, one for a tumor that is removed from inside the heart (intracardiac) and one for a tumor that is removed from outside the heart (external)
Both procedures are open surgical procedures that involve opening the chest, spreading the ribs, and excising the tumor
Transmyocardial Revascularization
Laser transmyocardial revascularization describes a procedure in which areas of cardiac ischemia (reversible muscle damage) are exposed to a laser beam to create holes in the surface of the heart
This procedure encourages new capillary growth, thereby revitalizing the damaged area by increasing the blood flow in the area
This procedure can be performed alone, as the only surgical procedure performed (33140), or at the time of another open cardiac procedure (add-on code 33141)
Pacemaker or Pacing Cardioverter- Defibrillator
A pacemaker and a pacing cardioverter-defibrillator (33202-33249) are devices that are inserted into the body to electrically shock the heart into regular rhythm (as illustrated in Figs
21-5 and 21-6)
When a pacemaker is inserted, a pocket is made and a generator and lead(s) are placed inside the chest (Fig
21-7)
Sometimes, only components of the pacemaker are reinserted, repaired, or replaced
You need to know three things about the service provided to correctly code the pacemaker:
1
Where the electrode (lead) is placed: atrium, ventricle, or both ventricle and atrium
2
Whether the procedure involves initial placement, replacement, upgrade or repair of all components or separate components of the pacemaker
3

The approach used to place the pacemaker (epicardial or transvenous)

CODING SHOT
A single pacemaker has one lead (atrium or ventricle), a dual pacemaker has two leads (one lead in the right atrium and one in the right ventricle), and a biventricular pacemaker has three leads (one in the right atrium, one in the right ventricle, and one on the left ventricle via the coronary sinus vein)

Approaches
The two approaches that are used when inserting a pacemaker are epicardial (on the heart) and transvenous (through a vein), and the codes are divided according to the surgical approach
1
The epicardial approach involves opening the chest cavity and placing a lead on the epicardial sac of the heart
A pocket is formed in either the upper abdomen or under the clavicle, and the pacemaker generator is placed into the pocket
The wires are then connected to the pacemaker generator and the chest area is closed
Codes for the epicardial process are further divided based on the approach to the heart—thoracotomy, upper abdominal (xiphoid region), or endoscopic
2
The transvenous approach involves accessing a vein (subclavian or jugular) and inserting an electrode (lead) into the vein
The pacemaker is affixed by creating a pocket into which the pacemaker generator is placed
The fluoroscopy views the internal structure by means of x-rays
Fluoroscopic guidance is included in 33206-33249
Diagnostic fluoroscopic guidance for diagnostic lead evaluation with lead insertion, replacement, or revision is reported with 76000
Transvenous codes are further divided based on the area of the heart into which the pacemaker is inserted
For example, 33207 (single-lead pacemaker) is reported for transvenous placement of a pacemaker into the ventricle of the heart
If the pacemaker electrodes were placed in both the atrium and ventricle, 33208 (dual-lead pacemaker) is reported
The documentation in the medical record will indicate whether a pacemaker or pacing cardioverter-defibrillator was inserted or replaced
The same set of criteria applies to choosing the correct cardioverter- defibrillator codes:
1
Revision or replacement of lead(s)
2
Replacement, repair, removal of components
3

Approach used for insertion or repair

If electrophysiology (EP) is used to diagnose a condition that resulted in the insertion of a pacemaker or cardioverter-defibrillator, the EP is not included in the surgery code reported for the insertion

Rather, the EP is reported separately using the Medicine section codes 93600-93660
Remember to use modifier -26 on a radiology service when only the professional portion of the service was provided and -TC when only the technical portion was provided
CODING SHOT
A change of batteries in a pacemaker or pacing cardioverter- defibrillator is a removal of the implanted generator and the reimplantation (insertion) of a new generator
Both the removal and the reimplantation are reported separately
CODING SHOT
If a patient with a pacemaker or other implantable device is seen by the physician within the 90-day follow-up (global) period for implantation but for a problem not related to the implantation, the service for the new problem can be billed
Documentation in the medical record must support the statement that the service is unrelated to the implantation
Append the E/M service code with modifier -24 (unrelated E/M service)
If the patient is returned to the operating room for repositioning or replacement of the pacemaker or pacing cardioverter-defibrillator during the global period by the same physician, modifier -78 would be appended to the code
Electrophysiologic Operative Procedures
Electrophysiology, as you learned earlier in this chapter, is the study of the electrical system of the heart, and most of the codes for the EP tests are in the Medicine section
The codes in the Surgery section (33250- 33266) apply to the surgical repair of a defect that causes an abnormal rhythm
Cardiopulmonary bypass is usually required during these major operative procedures in which the chest is opened to expose the heart to the full view of the surgeon
Codes 33265 and 33266 are used to report endoscopic approach for EP procedures
The surgeon maps the locations of the electrodes of the heart and notes the source of the arrhythmia
The source of the arrhythmia is then ablated (separated)
The codes are divided on the basis of the need for cardiopulmonary bypass, the reason for the procedure (atrial fibrillation, atrial flutter, etc
), and the approach
Percutaneous electrophysiology is discussed later in this chapter under the heading Intracardiac Electrophysiologic Procedures/Studies
Patient-Activated Event Recorder
A patient-activated event recorder is also known as a cardiac event recorder or a loop recorder
Codes 33282 and 33284 involve surgical implantation into the subcutaneous tissue of the upper left quadrant
The recorder senses the heart’s rhythms, and when the patient presses a button, the device records the electrical activity of the heart
The recording can assist the physician in making a diagnosis of a hard-to-detect rhythm problem
Codes are divided on the basis of whether the device was implanted or removed
Cardiac Valves
The category Cardiac Valves (33400-33478) has subcategory codes of aortic, mitral, tricuspid, and pulmonary valves
The procedures listed are similar for each valve
some are a little more extensive than others
Code descriptions vary depending on whether a cardiopulmonary bypass (heart-lung) machine was used during the procedure
The cardiopulmonary bypass is a resource- intensive procedure that requires a heart-lung machine to assume the patient’s heart and lung functions during surgery
The cardiac valve procedures are located in the CPT manual index under the valve type or under what was done, such as a repair or a replacement
For example, the replacement of an aortic valve is located in the CPT index under “Aorta,” subterm “Valve,” subterm “Replacement

The aortic valve controls the flow of blood from the left ventricle to the aorta
When a patient has aortic valve stenosis the flow of blood is restricted
Medications or balloon valve angioplasty are the less invasive treatments
however, valve replacement may be required
Codes 33361-33369 report transcatheter aortic valve replacement (TAVR) and transcatheter aortic valve implant (TAVI)
The delivery catheter is inserted into an artery using a percutaneous, open, or transaortic approach
Codes 33361-33365 are divided based on the approach
Codes 33367-33369 are add-on codes that are reported when the TAVR/TAVI are performed in addition to a more primary procedure
Coronary Artery Anomalies
The Coronary Artery Anomalies category (33500-33507) contains codes to report the services of repair of the coronary artery by various methods, such as graft, ligation (tying off), and reconstruction
The codes include endarterectomy (removal of the inner lining of an artery) and angioplasty (blood vessel repair)
Do not unbundle the codes and report the endarterectomy or angioplasty separately
Also, the procedures often require the use of cardiopulmonary bypass to allow the surgeon to repair the defect while the heart is without blood flow, which makes a difference in the choice of codes
Coronary Artery Bypass
Arteries deliver oxygenated blood to all areas of the body, and veins return the blood that is full of waste products
The heart muscle is fed by coronary arteries that encircle the heart
When these arteries clog with plaque (atherosclerosis) (Fig
21-8), the flow of blood lessens
Sometimes the arteries clog to the point that the heart muscle begins to perform at low levels due to lack of blood (reversible ischemia) or actually die (irreversible ischemia)
Reversible ischemia means that if the bloodflow is increased to the heart muscle, the heart muscle may again begin to function at normal or near- normal levels
Coronary artery bypass grafting is one way to increase the flow of blood (as illustrated in Fig
21-9)
The diseased portion of the artery is bypassed by attaching a healthy vessel above and below the diseased area and allowing the healthy vessel to then become the conduit of the blood, thus bypassing the blockage (Fig
21-10)
Blockage can also be pushed to the sides of the coronary arterial walls by a procedure in which a balloon is expanded inside the artery
This procedure is known as a percutaneous transluminal coronary angioplasty (PTCA) (Fig
21-11)
To correctly report coronary bypass grafts, you must know whether an artery (33533-33536), a vein (33510-33516), or both (33517-33523, plus 33533-33536) are being used as the bypass graft
You must also know how many bypass grafts are being performed
There may be more than one blockage to be bypassed and, therefore, more than one graft
If only a vein is used for the graft (most often the saphenous vein from the leg is harvested and used for this purpose
see Fig
21-10), the code reflecting the number of grafts would be assigned from the category Venous Grafting Only for Coronary Artery Bypass (33510-33516)
CODING SHOT
Modifier -51 would not be assigned with the code for the venous grafts because codes 33517-33523 are add-on codes
Parenthetical notations with each code indicate the code is to be used in conjunction with 33533-33536
This means that the venous code is never reported alone but always follows an arterial code
Arteries and Veins
Code groupings for arteries and veins vary according to procedures such as thrombectomies, aneurysm repairs, bypass grafting, repairs, angioplasties, and all other procedures
Codes in the subheading Arteries and Veins (34001- 37799) refer to all arteries and veins except the coronary arteries and veins (Figs
21-12 and 21-13)
Arteries of the body
Basilar artery
Right common carotid artery
Vertebral artery
Subclavian (right) artery
Brachiocephalic trunk
Aortic arch
Ascending aorta
Abdominal aorta
Internal iliac artery
Deep femoral (profunda) artery
Femoral artery
Popliteal artery
Circle of Willis
Internal carotid artery
External carotid artery
Left common carotid artery
Vertebral artery
Subclavian (left) artery
Descending aorta
Axillary artery
Celiac trunk
Brachial artery
Radial artery
Ulnar artery
Anterior tibial artery
Posterior tibial artery
Veins of the body
Superior vena cava
Inferior vena cava
Common iliac vein
Deep femoral vein
Common iliac vein
Internal iliac vein
External iliac vein
Great saphenous vein
Femoral veinVascular Families— Selective or Nonselective Placement
A vascular family can be compared to a tree with branches

The tree has a main trunk from which large branches and then smaller branches grow
The same is true with vascular families
A main vessel is the main trunk, and other vessels branch off from the main vessel
Vessels connected in this manner are considered families
Catheters, as shown in Fig
21-14, may have to be placed in vessels for monitoring, removal of blood, injection of contrast materials, or infusion
When coding the placement of a catheter it is necessary to know where the catheter starts and where it ends
Catheter placement is nonselective or selective
Nonselective catheter placement means the catheter or needle is placed directly into an artery or vein (and not manipulated farther along) or is placed only into the aorta from any approach
Selective catheter placement means the catheter must be moved, manipulated, or guided into a part of the venous or arterial system other than the aorta or the vessel punctured (that is, into the branches), generally under fluoroscopic guidance
The following codes illustrate nonselective and selective placement:
Code 36000 describes the placement of a needle or catheter into a vein with no further manipulation or movement
Code 36012 describes the placement of a catheter into a vein and its manipulation or moving to a second-order vein or farther
The first note in the Cardiovascular System subsection in the CPT manual (before code 33010) refers to selective placement
The note appears at the beginning of the section because it is very important and applies to the entire Cardiovascular System subsection
When coding selective placement for any procedure, you report the fullest extension into one vascular family, just as you would when coding a gastrointestinal endoscopic procedure, when you report to the farthest extent of the procedure
The same is true of selective placement into a vascular family: Code to the farthest extent of the placement within the vascular family
The first order is the main artery in a vascular family, the second order is the branch off the main artery, the third order is the next branch off the second order, and so on
A vascular family can have more than one second-order, third-order, and so on, vessel, as illustrated in Fig
21-15
Note that the first order in Fig
21-15 is the brachiocephalic artery, the second order is the common carotid artery, and that there are two third-order arteries
If the farthest extent of the placement was to the third order, only the third-order code would be reported
For example, if a catheter was placed into the first-order brachiocephalic artery and from there manipulated through the second-order artery (right common carotid), and finally into the third-order artery (right internal or external carotid), you would report only the third-order artery, with code 36217, which describes an initial third- order placement within the brachiocephalic family
Example
Nonselective:
36000 Introduction of needle or intracatheter, vein
Selective: 36012 Selective catheter placement, venous system
second order, or more

selective, branch

If the catheter placement continued from one branch of the brachiocephalic family into another branch of the family, you would report the additional second order, third order, and beyond using an add-on code—36218

Oftentimes, a physician will investigate not only one branch of an artery but several others
Report all subsequent catheter placement to the farthest extent of each placement
Catheter placement codes may vary according to the vascular family into which the catheter is placed
Look at the example of the two codes below and note the difference in vascular families
CODING SHOT
Appendix L of the CPT manual is a listing of the vascular families based on the starting point of the aorta
CODING SHOT
Code to the farthest extent of the vascular family using an initial code
then code any additional services of the second order, third order, or beyond by using an add-on code
Example
36215
Selective catheter placement, arterial system

each first order thoracic or brachiocephalic branch, within a vascular family

36245

Selective catheter placement, arterial system

each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family

F I G U R E

2 1 – 1 5
Brachiocephalic vascular family with first-, second-, third-, and fourth-order vessels
External carotid artery
Third orderCommon carotid artery
Second order

Aorta

Lingual artery
Fourth order

Internal carotid artery
Third order

Brachiocephalic artery
First order

Embolectomy/Thrombectomy

An embolus is a mass of undissolved matter that is present in blood and is transported by the blood
A thrombus is a blood clot that occludes, or shuts off, a vessel
When a thrombus is dislodged, it becomes an embolus
Thrombectomies or embolectomies are performed to remove the unwanted debris, or clot, from the vessel and allow unrestricted bloodflow
A thrombus or embolus may be removed by opening the vessel and scraping out the debris or by percutaneously placing a balloon within the vessel to push the material aside and out of the vessel (see Fig
21-11)
A catheter may also be used to draw a thrombus or embolus out of the vessel, as illustrated in Fig
21-16
Embolectomy/Thrombectomy codes (34001-34490) are divided based on the artery or vein in which the clot or thrombus is located (e
g
, radial artery, femoropopliteal vein), with the site of incision specified in the code description (e
g
, arm, leg, abdominal incision)
You can locate these codes in the CPT manual index under “Embolectomy” or “Thrombectomy,” subdivided by arteries and veins (e
g
, carotid artery, axillary vein)
When more involved procedures such as grafts are performed, inflow and outflow establishment is included in the major procedure codes
This means that if a thrombus is present and a bypass graft is performed, the removal of the thrombus is bundled into the grafting procedure if performed on the same vessel
Also bundled into the aortic procedures is any sympathectomy (interruption of the sympathetic nervous system) or angiogram (radiographic view of the blood vessels)
Vascular Repairs
The category Venous Reconstruction (34501-34530) contains codes for the various repairs made to the vena cava, saphenous vein, and valves of the femoral vein
The repair to valves is made by opening the site and clamping off the vessels
The surgeon then opens the vein and tacks down excess material of the valve with sutures (plication)
If there is a defect in the vein, the surgeon repairs the defect with a graft, usually harvested from elsewhere in the body
Vein repairs are performed by locating the defective vessel, clamping the vessel off, and bypassing or grafting the defect
The category Direct Repair of Aneurysm or Excision (Partial or Total) and Graft Insertion for Aneurysm, Pseudoaneurysm, Ruptured Aneurysm, and Associated Occlusive Disease (35001-35152) contains aneurysm repair codes that are divided according to the type of aneurysm and the vessel the aneurysm is located in (subclavian artery, popliteal artery)
The aneurysm is formed by the dilation of the wall of an artery
it is filled with fluid or clotted blood
During repair, the aneurysm is located, and clamps are placed above and below it
The section containing the aneurysm is then removed or bypassed
The aneurysm codes often refer to a pseudoaneurysm (false aneurysm), which is an aneurysm in which the vessel is injured and the aneurysm is being contained by the tissue that surrounds the vessel
Endovascular aneurysm repair (EVAR) is a technology that involves placing a stent graft, a fabric tube, inside the affected area of the blood vessel accessed through an artery
For example, abdominal aortic aneurysm repair by endovascular technique is reported with codes 34800-34834, and iliac aneurysm endovascular repair is reported with 34900
Repair, Arteriovenous Fistula category codes (35180-35190) are reported for fistula repair and are divided on the basis of whether the fistula (abnormal passage) is congenital, acquired, or traumatic
An arteriovenous fistula occurs when blood flows between an artery and a vein
An example of an acquired arteriovenous fistula is the creation of an arteriovenous connection that is used for a hemodialysis site (Fig
21-17)
In repairing a fistula, the surgeon separates the artery and vein and then patches the area of separation with sutures or a graft
If an angioscopy of the vessel or graft area is performed during a therapeutic procedure, code 35400, Angioscopy (noncoronary vessels or grafts) during therapeutic intervention, is listed in addition to the procedure code
For example, the surgeon performed the repair of an acquired arteriovenous fistula of the neck (35188) and then placed a scope into the artery to determine visually whether the repair was complete
Code 35188 describes the primary therapeutic procedure of repair of the acquired arteriovenous fistula, and 35400 describes the use of the angioscope to accomplish the repair
Note that 35400 is an add-on code and cannot be reported alone, but only in conjunction with another procedure code
A transluminal angioplasty is a procedure in which a vessel is punctured and a catheter is passed into the vessel for the purposes of widening a narrow or obstructed vessel by inflating a balloon
The category codes 35450-35476 are divided on the basis of whether the catheter was passed into the vessel by incising the skin to expose the vessel (open) or by passing the catheter through the skin (percutaneous) into the vessel
Further divisions of the codes are based on the vessel into which the catheter is placed (e
g
, iliac, aortic)
Bypass Grafts, Veins
As with coronary artery bypass grafting (CABG), you must know the type of grafting material used for vascular bypass grafts (Bypass Grafts 35500- 35671)
Grafts can be vessels harvested from other areas of the body or they may be made of artificial materials
Codes are chosen on the basis of the type of graft and the specific vessel(s) that the graft is being bypassed from and to
For example, 35506 describes a graft that is placed to bypass a portion of the subclavian artery
During this procedure the surgeon sews a harvested vein to the side of the carotid artery and attaches the other end of the vein to the subclavian artery below the damaged area, creating a bypass around the defect
One way to locate the graft codes in the CPT manual index is to reference
“Bypass Graft” and then the subterm type (e
g
, carotid, subclavian, vertebral)
Vascular Access
Some treatments are administered through the blood by means of vascular access
For instance, in patients receiving hemodialysis, arteriovenous fistulas may be created for dialysis treatments (see Fig
21-17)
This means that an artificial connection is made between a vein and an artery, allowing blood to flow from the vein through the graft for dialysis (cleansing of waste products) and then be returned to the artery
Vascular Injection Procedures
Bundled into the vascular injections (36000-36522) are the following items:
n
Local anesthesia
n Introduction of needle or catheter
n Injection of contrast media
n Pre-injection care related to procedure
n Post-injection care related to procedureVascular injections bundles do not include the following items:
n Catheter
n Drugs
n Contrast media
For items not bundled into the injection procedure, report each item separately

Code 99070 (supplies and materials) from the Medicine section or HCPCS supply codes report items such as catheters, drugs, and contrast media if the procedure is performed in the clinic facility
If the procedure is performed in the hospital catheterization laboratory, the hospital-based coder would report the supply
As previously discussed, knowledge of the vascular families is critical in coding vascular injection procedures because the initial placement and the extent of placement are usually the characteristics that determine the codes
You now know that the initial placement of the catheter is reported first and that add-on codes report any additional services

For example, review the following initial and additional third-order placement code descriptions in this example:

CAUTION

Just for a moment, think about what a difference a seemingly small fact—such as what is included in the vascular injection procedures— makes in the amount received for the procedure over the course of a year! It is your responsibility as the coder to know the rules of coding to ensure appropriate reimbursement for services provided by physicians
Details are important in the business of coding!
Example
36217
Selective catheter placement, arterial system

initial third order or more selective thoracic or brachiocephalic branch, within a vascular family

36218

Selective catheter placement, arterial system

additional second order, third order, and beyond, thoracic or brachiocephalic branch, within a vascular family

In the service described in 36217, the physician inserts a needle through the skin and into an artery

The needle has a guidewire attached to it, as illustrated in Fig
21-18, and when the needle is withdrawn, the guidewire is left inside the artery
The guidewire can then be manipulated into the particular artery
Once the guidewire is in the correct artery, a catheter is threaded into place over the guidewire and into the first-order brachiocephalic artery
The catheter is manipulated through the second-order artery and arrives at the third-order artery, where contrast material is injected into the artery through the catheter and an arteriography is completed
After the completion of the service described in 36217, the physician pulls the catheter back into the artery and then manipulates the catheter into another third-order artery (36218), where contrast material is again injected into the artery through the catheter and another arteriography is completed
FIGURE
21-19 Arterial Head and Neck approach is common femoral
Right internal carotid
36217
Right external carotid 36217
Right common carotid 36216
Right thyrocervical trunk and branches 36217
Right costocervical trunk 36217
Right axillary 36217
Right subclavian 36216
Right internal mammary/thoracic 36217
36216 Left internal carotid
36216 Left external carotid
Right vertebral 36217
Left common carotid 36215
Left vertebral 36216
Left subclavian 36215
Left internal mammary/thoracic 36216
Left axillary 36216
Brachiocephalic or innominate 36215
Ascending aorta 36200
Right intercostals 36215
36215 Left intercostals
Sternocleidomastoid
36217 Occipital
36217 36217 Submental
Parietal branch superficial temporal 36217
Posterior branch middle meningeal 36217
Mastoid 36217
Frontal branch of superficial temporal 36217
36217 Zygomaticorbital
36217 Middle temporal
36217 Middle meningeal
F I G U R E
2 1 – 2 0 Arterial Head and Neck—right external carotid approach is common femoral
Right external carotid
Right common carotid
36217
36216 36217
36217 36215
Left common carotid
Right vertebral Right subclavian 36216
36215
Brachiocephalic or innominate
36215
36217
36217 36217 Superior thyroid
Maxillary 36217
36217 Superior labial
36216
Left vertebral
Left subclavian
Right internal carotid
Inferior labial
LingualCARDIOVASCULAR CODING IN THE MEDICINE SECTION
Services in the Cardiovascular subsection of the Medicine section (92920- 93799) can be either invasive/noninvasive or diagnostic/therapeutic

The invasive treatments are not a matter of cutting open the body so the surgeon can view it, as was the case in the Cardiovascular subsection of the Surgery section, but are invasive in that there is an incision into or a puncture of the skin
Review the subheadings in the Cardiovascular subsection in the Medicine section of the CPT manual
Therapeutic Services
It is within the Therapeutic Services and Procedures subheading that you locate many commonly assigned cardiovascular codes, such as cardioversion, infusions, thrombolysis, placement of catheters and stents, atherectomy, and angioplasty
Many of these services used to be performed as open operative procedures, but with the advent of modern techniques, many are now performed by means of percutaneous access
Division of the codes is based on method (balloon, blade), location (aorta or mitral valve), and number (single or multiple vessels)
Thrombolysis, as described in 92975, is a percutaneous procedure in which the physician inserts a catheter into a coronary vessel and injects contrast material into the vessel to further enhance the visualization of a blood clot
The clot is then destroyed by a drug that the physician injects through the catheter
The Medicine section code 92975 represents the total procedure when the thrombolysis is performed in a coronary vessel
If vessels other than the coronary vessels are treated, a code from the Surgery section, Cardiovascular subsection, would be assigned to report a transcatheter infusion for thrombolysis (see 37211-37214)
Intravascular ultrasound of the coronary vessels can be reported using the two codes 92978 and 92979, depending on the number of vessels being diagnosed
A needle is inserted percutaneously into the vessel and a guidewire introduced, followed by an ultrasound probe
The probe allows a two-dimensional image of the inside of the vessel to be viewed on the ultrasound monitor
The physician can assess the vessel before and after treatment
The physician may reposition the probe to assess additional vessels, and 92979 is reported to indicate this subsequent placement
Note that both 92978 and 92979 are add-on codes intended to be reported only in conjunction with the primary procedure
For example, intravascular ultrasound with coronary stent placement would be reported as 92928 (placement of stent) and 92978 (intravascular ultrasound)
Intracoronary stent placement (92928, 92929) is performed using a catheter to reinforce a coronary vessel that has collapsed or is blocked
The placement of the stent is usually accomplished with radiographic guidance which is included
The codes are divided on the basis of whether more than one coronary vessel was cleared of obstruction and had a stent placed within it
Fig
21-21 illustrates an angioplasty/stent report in which the coronary artery is repaired by placement of a stent
Percutaneous transluminal coronary angioplasty (PTCA) is described in codes 92920 and 92921
The codes are divided on the basis of whether a single vessel or additional vessels are treated during the procedure
Add-on code 92921 (PTCA for each additional vessel) is of interest because it can be assigned not only with 92920, but also with other codes in the category
For example, 92921 can be assigned with 92928, placement of a stent, when a stent is placed in one vessel and the PTCA is performed in a different vessel
If a patient had an intracoronary stent placed in one coronary vessel, report 92928, and if the physician also performed a PTCA on another coronary vessel, report 92921
This is the first time that you have used an add-on code with a code other than the one(s) that appears directly above it in the same group of codes, so be certain to read the code descriptions for each of the codes used in the example and pay special attention to the notes that follow 92921
CODING SHOT
There are HCPCS modifiers to identify the specific coronary arteries that are treated, such as -RC, right coronary
-LC, left circumflex
and -LD, left anterior descending
Valvuloplasty can also be performed by inserting a catheter percutaneously
The procedure opens a blocked valve by using a balloon, which is inflated to clear the blockage
Codes 92986-92990 are divided based on the valve being repaired
The balloon technique is also used to treat congenital heart defects such as vessels that are too narrow
A blade can also be deployed inside the coronary vessels
A special catheter that has a retractable blade is guided into the vessel and the surgeon manipulates the blade to enlarge the area, using ultrasound or fluoroscopic guidance
Cardiography
This category (93000-93278) of the Cardiovascular System subsection contains frequently assigned codes, such as those for electrocardiograms and heart monitoring, which are certain to be used in most office practices, even if the practice does not include a cardiologist
The Cardiography subheading codes report electrocardiographic procedures such as stress tests
Stress tests are performed to assess the adequacy of the amount of oxygen getting to the heart muscle (at rest and during exercise) and thus indicate the presence or absence of heart disease (Fig
21-22)
The top number on a blood pressure reading is systole (heart muscle is contracting)
the bottom number is diastole (heart muscle is relaxing)
The heart muscle is fed by three coronary arteries and their branches
If these arteries are clear, the amount of blood going to the muscle is adequate during rest and exercise
The heart muscle is fed only during diastole
Normal blood pressure is about 120/80 mm Hg, and the normal heart rate is about 60-100 beats per minute
During low blood pressure, little blood and oxygen get to the heart
As the heart beats faster, such as during exercise, the heart rate increases and diastolic pressure time decreases, meaning that there is less time to supply blood to the heart muscle
As the heart beats faster, more oxygen is required
With narrowing of coronary arteries and branches, too little blood may circulate to the heart muscle, supplying even less oxygen than during rest
Chest pain may result as an indication that heart muscle tissue is dying
Indications of heart disease during a stress test are chest pain and a depressed or elevated ST wave segment on the ECG, as illustrated in Fig
21-23
The Holter monitor, as illustrated in Fig
21-24, is similar to an electrocardiogram (ECG), as illustrated in Fig
21-25, in that leads are attached to the patient
There are portable Holter monitors that record the patient’s ECG readings for 24 hours
Leads are attached to the chest and to a cassette machine
The monitor converts the ECG readings to sound, and the sound is converted back to an ECG reading when completed
The reading is then sped up to hundreds of times faster than normal by computers
Any reading that varies from a normal reading will be identified
The Q, R, and S waves are related to the contraction of the ventricles of the heart
The QRS waves and heartbeats can be monitored by Holter monitors
Cardiac arrhythmias can be identified using the Holter monitor process
CODING SHOT
If only the interpretation and report are done with an SAECG, report 93278-26 to indicate that only the professional component was provided
An ECG is typically conducted by attaching 10 electrodes (leads) to the patient’s chest to monitor 12 areas
The ECG provides a reading of the electrical currents of the heart and is a standard test conducted to detect suspected cardiac abnormalities, such as arrhythmias and conduction abnormalities
Codes report the tracing only (the technical component), the interpretation and report only (the professional component), or the entire procedure of tracing and interpretation (the technical and professional components)
The medical record will indicate the components provided
Codes 93000-93010 are for the standard 12-lead ECG
the codes are divided on the basis of the component(s) provided
Codes 93040-93278 report other various ECGs and are divided according to the type of recording and the component(s) provided
Only careful reading will reveal the often slight differences between codes
Of special note is signal-averaged electrocardiography (SAECG) reported with 93278
SAECG is a type of electrocardiography that can help physicians predict certain tendencies to abnormalities such as ventricular tachycardia
The signal is recorded during nine periods, each lasting 10 to 20 minutes, and the computer manipulates the data produced and predicts certain tendencies
The SAECG is a more sophisticated ECG than the standard ECG and is used when a standard ECG is unable to demonstrate the suspected conductive abnormalities
Telephonic transmission of an external patient-activated electrocardiogram records irregular rhythms
The readings can then be sent to the physician by means of a telephone to transmit the information, which is subsequently printed for the physician’s review
Third-party payers usually restrict the payment of telephonic transmissions to one every 30 days
The codes 93268-93272 are divided on the basis of the component(s) that were provided
A cardiovascular stress test is used to evaluate and diagnose chest pain, to screen for heart disease, to evaluate irregular heart rhythms, and to investigate many other cardiovascular abnormalities
The patient is placed on a treadmill or a stationary bicycle and ECG leads are attached
The patient then exercises until he or she reaches maximal (220 minus age) or submaximal (85% of maximal) heart rate
During certain intervals, recordings are taken by means of ECG, heart rate, and blood pressure of the patient
The codes for stress tests (93015-93018) are divided on the basis of the components provided
Code 93015 reports the global outpatient service, and 93016-93018 reports components (parts) of the service
The ECG is bundled into the stress test, so do not unbundle and report an ECG or any reading separately
Medication can be administered to mimic the stressing of the heart and is used when factors are present that limit a patient’s ability to exercise, such as arthritis, morbid obesity, or stroke
Stress test codes are used for both stress-induced (exercise) and pharmacologically induced (drug) studies
Medications and radiology services may be reported separately
Implantable and Wearable Cardiac Device Evaluations
Cardiovascular monitoring is a diagnostic service that may be performed in person or using technology to access cardiovascular data, and these services are reported with codes in the 93279-93299 range
Codes 93279-93285 are reported per procedure, such as a single, dual, or multiple lead pacemaker or pacing cardioverter-defibrillator programming device evaluation
There are extensive notes before the subheading that are must reading before you begin to assign these codes
Codes 93286 and 93287 report periprocedural (shortly before, during, or shortly after) evaluation of a device based on if the device is a pacemaker or cardioverter-defibrillator
The codes may be reported once before and once after surgery because they are the testing of the device to ensure it functions correctly
Codes in the 93288-93292 range are reported per procedure and are in- person evaluations of a pacemaker or cardioverter-defibrillator system based on the type of device and the type of analysis performed
Evaluation of a pacemaker by means of a telephone is reported once in a 90-day period with 93293
The service includes the written report of the data analysis
Face-to-face evaluations of the device are referred to as interrogation device evaluations and are reported with 93294-93299
These codes are divided based on the type of device (pacemaker or cardioverter-defibrillator) and the time period
For example, 93297 reports remote interrogation evaluation(s) up to 30 days and 93294 reports remote interrogation evaluation(s) up to 90 days
Echocardiography
Echocardiography is a noninvasive diagnostic method that uses ultrasonographic images to detect the presence of heart disease or valvular disease
A sliced image is used to detail the various walls of the heart
A transducer is placed on the outside of the chest wall, and it sends sound waves through the chest (Fig
21-27)
As the sound reflects back from each organ wall, dots are recorded, indicating the point of reflection
When the heart is in systole, it is contracting, and the dots on the recording appear farther apart
When the heart is in diastole, it is relaxing, and the dots on the recording appear closer together
Bundled into the complete echocardiography procedures (93303-93352) are the obtaining of the signal from the heart and great arteries by means of two-dimensional imaging and/or Doppler ultrasound, the interpretation, and the report
Modifiers -26, professional service only, and -TC, technical component, may be applied to these codes if only one component is provided
The codes are divided on the basis of whether it was a complete echocardiogram or a follow-up/limited study, the type of echocardiogram, and the approach used
Echocardiography
A transducer is placed on the outside of the chest wall, and it sends soundwaves through the chest
When the heart is in systole, the heart is contracting and the dots on the echocardiogram appear farther apart
When the heart is in diastole, it is relaxing and the dots on the echocardiogram appear closer together
Cardiac Catheterization
Catheterization (93451-93568) is an invasive diagnostic medical procedure in which the physician percutaneously inserts a catheter and manipulates the catheter into coronary vessels and/or the heart
Fig
21-28 illustrates a percutaneous method of catheterization called the Seldinger technique, after the inventor of the method
This catheterization is at the right subclavian artery
Following insertion of the fine-gauge needle, a guidewire and then a catheter are inserted
The cardiac catheter measures pressure, oxygen, and blood gases, takes blood samples, and measures the output of the heart
A cardiac catheterization is a study of both the circulation and the movement of the blood of the heart
the physician may inject a dye into the vessel or heart and observe the movement of the dye by means of angiography
When injection of contrast material is used to improve visualization, the injection is bundled into the Cardiac Catheterization code
Component coding requires you to examine services that were provided to the patient, identify each component, or part, of that service, identify who performed each component, and code each service provided
The three cardiac catheterization components of catheter placement, injection, and imaging are reported in one combination code
For example, 93456 includes catheterization, injection, and imaging
However, some cardiac catheterization codes require multiple codes
For example, 93531 reports catheterization for congenital cardiac anomalies, but the injection/imagining code (93563/93564) must be added to completely describe the service provided
Only careful reading of the code descriptions in the cardiac catheterization codes will result in correct coding
If the private physician (such as the clinic physician) performs the catheterization procedure in the catheterization laboratory at the hospital, you would add modifier -26 to the cardiac catheterization code
The hospital would submit charges for the technical component of the procedure
Access for cardiac catheterization can be made in several locations, depending on the patient’s condition and the physician’s preference—for example, the right femoral artery (access site)
Cardiac catheterization can indicate valve disorders, abnormal flow of blood, and a variety of cardiac output abnormalities
Often, a cardiac catheterization leads to a more definite treatment, such as a valvoplasty, stent placement, angioplasty, or bypass
Bundled into the cardiac catheterization codes are the introduction, positioning, and repositioning of the catheter(s)
the recording of pressures inside the heart or vessels
the taking of blood samples
rest/exercise studies
final evaluation
and final report
Injection codes 93563 and 93564 are only reported with cardiac catheterization codes 93530-93533, which are codes for cardiac catheterization for congenital abnormalities
These two injection codes are divided based on if the procedure was for “coronary angiography” (93563) or “aortocoronary venous or arterial bypass graft(s)” (93564)
Both codes also include the imaging service
The codes are listed in addition to the primary cardiac catheter procedure
There are also other injection codes (93565-93568) and these codes also include the imaging service
These injection codes are assigned with cardiac catheterization codes when additional injections are performed
For example, 93456 reports right heart catheterization with injections/ imagining/angiography
If the physician also performed an aortography, the code reported for this additional service would be 93567
There are several codes (93561-93572) in the category
These codes are for the indicator dilution studies, which are already bundled into the cardiac catheterization codes and are to be reported only when the complete cardiac catheterization procedure was not performed
For example, if only the dye or thermal dilution study was performed, without a cardiac catheterization, an indicator dilution study code would be assigned to report the service
Intracoronary
Brachytherapy
Intracoronary brachytherapy is the use of radioactive substances as a therapy for in-stent restenosis of a coronary vessel, as illustrated in Fig
21-29
For example, a patient has a coronary artery stent placed to open a vessel that is blocked with plaque (stenosis)
The stent reopens the vessel so blood can once again flow without obstruction
However, the stent can also become occluded with plaque and when this happens, the physician may use intracoronary brachytherapy in which a radioactive strip of material is inserted by means of a catheter into the area of blockage, where it is left for up to 45 minutes and then removed
The procedure would usually be performed by an interventional cardiologist and a radiation oncologist
The interventional cardiologist would place the radioactive-element guidewire and report that service with 92974, which is the catheter placement code
The radiation oncologist would then place the radioactive elements and report the services with codes 77785-77787
Intracardiac Electrophysiologic Procedures/Studies
As you learned earlier in this chapter, surgical electrophysiologic procedures (33250-33261) are those that repair the electrical system of the heart using invasive surgical procedures
In the Medicine section, the Intracardiac Electrophysiological Procedures/Studies category (93600-93662) contains codes that describe services that diagnose and treat the electrical system of the heart using less invasive procedures
Although the Medicine section procedures are invasive, they are percutaneous procedures, not open procedures
Fig
21-30 illustrates the electrical conduction system of the heart, which begins with the sinoatrial node (SA), known as the heart’s pacemaker
The sinoatrial node sends impulses to the atrioventricular (AV) node, which in turn passes the impulses to the bundle of His, and finally on to the Purkinje fibers to stimulate the muscle tissues of the ventricles of the heart to contract
Lesions or diseases involving these structures along the electrical conduction pathway underlie many of the disturbances of cardiac rhythm
To diagnose the origin of an electrophysiologic abnormality, the physician takes recordings at various sites along the pathway
The physician may also stimulate the heart to induce arrhythmia by means of a catheter attached to a pacing device that sends electrical impulses to various sites within the heart
A protocol (a set order) for the placement of the catheter is a programmed stimulation
Pacing is the regulation of the heart rate
A cardiac pacemaker is a permanent pacer
but the pacing referred to in the EP codes is a temporary pacing done in an attempt to stabilize the beating of the heart
Recording is a record of the electrical activity of the heart taken by means of an ECG
Recording services are reported with codes in the range of 93600-93603, and pacing services are reported with codes 93610 and 93612
Combination codes that indicate both recording and pacing begin with 93619
These codes are not used as much as they used to be when EP was a new technique and readings were commonly taken at just one site
Today, more complex EP studies are usually done, including multiple pacings and recordings in combinations based on established protocols using three or more catheters
These complex services are reported with codes in the 93619-93622 range
Carefully read the notes in parentheses following several of the combination codes, as the notes indicate when the use of the combination code is appropriate and even indicate the codes that are bundled into the one combination code
Bundle of His recording is a reading taken inside the heart (intracardiac) at the tip of the bundle of His
The bundle of His is also known as the atrioventricular bundle or AV bundle and is the bundle of cardiac muscle fibers that conducts electrical impulses that regulate heartbeats
The physician percutaneously inserts into a vessel a special catheter that can sense electrical impulses
The catheter is advanced to the right heart
The femoral vein is the usual site of entry, and fluoroscopic guidance is usually used for placement of the catheter into the heart
Codes 93602 and 93603 describe a single recording based on the location—intra-arterial or right ventricle
Codes 93610 and 93612 describe single intra-arterial or intraventricular pacing in an atrial or a ventricular location
Code 93631 reports pacing and mapping done during an open surgical procedure in which the surgeon opens the chest and exposes the heart
The EP physician performs the mapping (locating the origin of the arrhythmia and defining the pathway), and the surgeon then destroys the source of the arrhythmia
When reporting the services of both physicians for this procedure, use 93631 to report the mapping service and a surgery code from the range 33250-33261 to report the arrhythmia ablation
Make a notation next to the mapping code 93631 to report any surgical ablation (33250-33261) to remind yourself to code both procedures if required
If the mapping is not done intraoperatively (during surgery), report the service with 93609 or 93613
Ablation can also be performed by using a catheter with a tip that emits electric current
When the tip is placed on tissue and activated, the tissue is destroyed
Sometimes physicians destroy certain sites along the conduction pathway as a treatment for slow (bradycardia) or fast (tachycardia) heart rhythms
Ablation procedures are reported according to whether they were at the AV node (93650), a separate (93655) or an additional treatment (93657)
There are two ways ablation can be performed
The first way does not require open heart surgery
An area of the patient’s upper thigh is numbed, but the patient is awake
Then the physician inserts a thin tube through a blood vessel (usually the femoral vein) and all the way up to the heart
At the tip of the tube is a small wire that can deliver radiofrequency energy to burn away the abnormal areas of the heart
Then the heart can beat normally again
The second way ablation can be performed is by means of open heart surgery
In the Maze procedure, the surgeon makes small cuts in the heart to direct healthy electrical rhythms
In cryoablation, a very cold substance is used to freeze the cells that are creating problems
In endocardial resection, the surgeon removes a section of the thin layer of the heart where the abnormal rhythms originate
FIGURE
21-30 Electrical conduction system of the heart
Sinoatrial (SA) node
Right atrium
Atrioventricular (AV) node
Bundle of His
Right ventricle
Inferior vena cava
Aorta
Pulmonary artery
Purkinje fibers
Right and left bundle branchesCAUTION

Most of the EP codes have many items bundled into them, so read the description of each code completely so as to avoid unbundling the services

Peripheral Arterial Disease Rehabilitation

Peripheral arterial disease (PAD) rehabilitation sessions (93668) last 45 to 60 minutes

these are rehabilitative physical exercises done either on a motorized treadmill or on a track to build the patient’s cardiovascular endurance
An exercise physiologist or nurse supervises the sessions
If a session produces symptoms of angina or other negative symptoms, the physician reviews the information and may determine to re-evaluate the patient
The physician services are not included in the PAD codes, rather the physician services are reported with an additional Evaluation and Management (E/M) code
Noninvasive Physiologic Studies and Procedures
CARDIOVASCULAR CODING IN THE RADIOLOGY SECTIONIf a patient has a pacemaker or defibrillator in place, periodic monitoring must occur to ensure that the device is functioning properly
Codes from the Noninvasive Physiologic Studies and Procedures (93701-93790) category and the Implantable and Wearable Cardiac Device Evaluations (93279- 93299) category reflect these services
Codes are assigned according to the type of pacemaker (single- or dual-chamber) or cardioverter-defibrillator and whether reprogramming of an existing pacemaker or defibrillator was done
Ambulatory blood pressure monitoring (93784-93790) is an outpatient procedure that is conducted over a 24-hour period by means of a portable device worn by the patient
There is a code for the total procedure— including recording, analysis, and interpretation/report—and there are codes for each of the individual components—recording only, analysis only, and interpretation/report only
The Other Procedures codes (93797-93799) report physician services that are provided for cardiac rehabilitation of outpatients, either with or without electrocardiographic monitoring

CARDIOVASCULAR CODING IN THE RADIOLOGY SECTION

The Radiology section of the CPT manual used to contain combination codes that included both the professional and technical components in one code

For example, 75659 existed to report the services of both the angiography (technical component) and the injection procedure (professional component) in a brachial angiography procedure
When the complete procedure code, 75659, was deleted, the injection procedure (professional component) was moved to the Surgery section and a code to report the technical component (angiography) remained in the Radiology section
Now, to report both the injection procedure and the angiography services (the complete procedure), the coder assigns a Surgery code to report the professional component and a Radiology code to report the technical component
The division of the technical and professional components makes it possible to specify the various parts of a procedure, which is important because some cardiologists perform both components of these cardiovascular procedures, and some cardiologists perform only the injection procedure and have a radiologist do the angiography portion of the procedure
Component coding allows for the flexibility necessary to report these various situations
Component coding also makes it easier to identify the various diagnostic tests used in cardiovascular conditions
For example, one cardiologist may prefer to use an ultrasonic procedure in the diagnosis of arterial stenosis and another may prefer angiography
Both procedures require the insertion of a catheter and, as such, the insertion code remains the same, but the diagnostic tools may change
Radiology codes often contain the statement “supervision and interpretation
” Supervision is the radiologist’s overseeing of the technician who is performing the procedure or indicates that the radiologist is performing the procedure himself/herself
Interpretation is the summary of the findings, also known as the final report, and the radiologist or cardiologist may do this portion of the service
There are actually two components (parts) in a code with supervision and interpretation in the description—the professional and technical components
The technical component is the equipment and the technician who actually provides the service
The professional component is the interpretation of the results and the writing of a report about the results, as illustrated in Fig
21-31
Both components are not necessarily done by the same organization
Let’s take an x-ray as an example of a service and see how you report the components
If a clinic owns its own x-ray equipment and employs a radiologist to interpret the x-rays and write the reports, and also employs the technician who, under the supervision of the radiologist, takes the x-rays, the clinic could report the x-ray service using the appropriate radiology code, with supervision and interpretation in the description and no modifier
The clinic provides the total service, also known as the global service
Another clinic owns the equipment and employs the technician who takes the x-ray, but then the clinic sends the x-ray out to a radiologist at another clinic who reads the x-ray and writes the report
The radiologist would report the service with the appropriate radiology code and modifier -26 to indicate that he or she provided only the professional component of the service
The clinic that employs the technician and owns the equipment would report the same radiology code but would attach the HCPCS modifier -TC (technical component) to indicate that only the technical component of the service was provided
A third clinic has no x-ray equipment, so the physicians in the clinic send patients to an outside radiologist who hires the technician who takes x-rays on equipment owned by the radiologist, the radiologist interprets the results, and writes the report
The outside radiologist would report the service using the global radiology code with no modifier, because both the professional component and the technical component were provided
Contrast material is commonly used with radiology procedures to enhance the image
If the Radiology section code states “with contrast” or “with or without contrast,” you will know that the injection of contrast material and the contrast material itself (the substance used for contrasting) are bundled into the code
therefore, you would not report the contrast material or injection separately
If, however, there is no indication of contrast in the code description, and the physician used contrast, you would code both the injection of the contrast material and the contrast material itself
Injection of contrast is usually included in the radiology code
If guidelines state that you should report injections separately, report with the appropriate code from the Surgery section—for example, 47500, Injection procedure for percutaneous transhepatic cholangiography, and 74320 for the radiology portion of the service
The contrast material is reported separately using code 99070 from the Medicine section or with a HCPCS code
CODING SHOT
Not all contrast material can be reported separately! Oral or rectal contrast is considered a part of the procedure and is not reported separately
Intravenous, intra-arterial, or intrathecal (fluid-filled space between the layers of tissue covering the brain and spinal cord) injection of contrast material can be reported separately if the code description does not refer to inclusion of contrast material
STOP Now, don’t get discouraged with all of these codes from all of these sections! Remember that only with repeated use of these codes can you master them
At first, it sounds so confusing that you might wonder if you can ever absorb all of this information and the variations
You can! But you must be patient with the process
To be a coder is to be able to concentrate on details and commit yourself to the process of learning the details through repeated use
Everyone starts at the same place
Now, let’s get back to learning about component coding
Two physicians, a cardiologist and a radiologist from the same facility, perform an angiography of the brachiocephalic artery (first order) using contrast material
Access was the right femoral artery
The coding is as follows:
n
Cardiologist placing the catheter: 36215, Surgery section
n Radiologist performing the angiography: 75710, Radiology section
n Supply of the contrast material: 99070, Medicine section, or HCPCS
Level II code (such as A4641, Radiopharmaceutical, diagnostic)Two physicians, a cardiologist and a radiologist from different facilities, perform an angiography of the brachiocephalic artery (first order) using contrast material

The coding for the cardiologist is as follows:
n
Cardiologist placing the catheter: 36215, Surgery section
The coding for the radiologist is as follows:
n Radiologist performing the angiography: 75710, Radiology section
n Supply of the contrast material: 99070, Medicine section, or a HCPCS
Level II code (such as A4641, Radiopharmaceutical, diagnostic)CODING SHOT
If the radiologist is at the same facility as the equipment, you report 75710 (angiography)

If the angiography was performed at the hospital and the radiologist from a clinic read the angiography, the radiologist would report 75710-26 and the hospital would report 75710-TC
Heart
The Heart subsection (75557-75574) of the Radiology section contains codes that report cardiac magnetic resonance imaging (MRI) of the heart
An MRI, as illustrated in Fig
21-32, A and B, is the use of radiation to show the body in a cross-sectional view
MRI may include the use of injectable dyes (radiographic contrast) to aid in imaging
Other MRI codes are located throughout the Radiology section according to the body part being imaged, but the codes in the Heart subsection are just for cardiac MRIs
Aorta and Arteries
In Radiology, the Aorta and Arteries subsection (75600-75791) includes codes for aortography excluding the heart—thoracic, abdominal, cervicocerebral, brachial, external carotid, carotid, vertebral, spinal, extremity, renal, visceral, adrenal, pelvic, pulmonary, and internal mammary
The Aorta and Arteries subsection codes are reported with coding components of cardiovascular services

STEP BY STEP BOOK I COMPLETED

Section Objectives
Understand the Cardiovascular System guidelines
Understand coding for different pacemaker systems
Understand coding for coronary artery bypass procedures
The Cardiovascular System section of the CPT codebook contains codes for reporting procedures of the heart and pericardium, arteries, and veins

(See Figures 4-52 and 4-53
)
The focus of this chapter is on guidelines associated with certain techniques (eg, epicardial, transcatheter, thoracotomy, sternotomy, open, endovascular) and technology (eg, endovascular modular grafts, pacing cardioverter defibrillators, permanent pacemakers) used to perform diagnostic and therapeutic procedures of the heart and lungs and peripheral and coronary vascular systems
(See Figures 4-54 and 4-55
)
FIGURE 4-52 Basic Vascular Anatomy of the HeartFIGURE 4-53 Basic Anatomical Structures of the Heart

FIGURE 4-54 Blood Flow Through the Heart and Lungs

FIGURE 4-55 Anterior View of the Heart

For single- and dual-chamber pacemaker systems, epicardial placement of the electrode should be separately reported using 33202 and 33203

Pacemaker Systems
A pacemaker system includes a pulse generator (containing electronics and a battery) and one or more electrodes (leads)
The pulse generator is placed in a subcutaneous pocket created either in an infraclavicular site or underneath the abdominal muscles just below the ribcage
Electrodes (leads) may be inserted through a vein (transvenous) or placed on the surface of the heart (epicardial)
Epicardial placement of electrodes requires a thoracotomy or sternotomy
In addition to the various placement methods, different types of systems may also be inserted
A single-chamber pacemaker system includes a pulse generator and one electrode inserted in either the atrium or the right ventricle
A dual-chamber pacemaker system involves the insertion of electrodes into both the atrium and the right ventricle that are then connected to a pulse generator capable of pacing and sensing both the atrium and the ventricle
(See Figures 4-56 and 4-57
)
In certain circumstances, an additional electrode may be required to achieve pacing of the left ventricle (bi-ventricular pacing)

FIGURE 4-56 Implanted Pacemaker (33212)

FIGURE 4-57 Implanted Pacemaker (33213-33214)

Biventricular pacing systems (see Figure 4-58) are used when pacing of the left ventricle is required in addition to pacing of the right ventricle

The implant procedure for the biventricular system is similar to that of a single- or dual-chamber system, with the additional complexity of the transvenous placement of the lead in a cardiac vein to reach the left ventricle
Implantation of a biventricular system requires a coronary guide catheter and the use of venography to guide the lead through the coronary sinus and into a cardiac vein for placement in the left ventricle
In this event, transvenous (cardiac vein) placement of the electrode should be separately reported using code 33224 or code 33225
A permanent pacemaker system (generator and electrode[s]) is removed, and a pacing cardioverter-defibrillator system is replaced (at the same operation)
(See Figure 4-58
)
In the instance in which a permanent pacemaker system (pulse generator and electrode[s]) is removed and replaced with a pacing cardioverter-defibrillator system (at the same operation), codes 33233, 33234, or 33235 would be reported in addition to code 33249
The assessment and reassessment of the pacing cardioverter-defibrillator electrodes related to sensing, pacing and electrode impedance characteristics at the time of insertion, repair, revision, or replacement is additionally reported using codes 93640 and 93641
1
Describe what a pacemaker system is

FIGURE 4-58 Biventricular Pacing

The assessment and reassessment of the pacing cardioverter-defibrillator electrodes related to sensing, pacing, and electrode impedance characteristics at the time of insertion, repair, revision, or replacement are additionally reported using codes 93640 and 93641

For pacing cardioverter-defibrillator systems, epicardial placement of the electrode should be separately reported using 33202 and 33203
Pacing Cardioverter-Defibrillator Systems
The combination pacing cardioverter-defibrillator ICD (system) is designed to recognize and provide antitachycardia pacing, low-energy cardioversion or defibrillating shocks to treat ventricular tachycardia or ventricular fibrillation
A pacing cardioverter-defibrillator system includes a pulse generator and electrodes, although pacing cardioverter-defibrillators may require multiple leads, even when only a single chamber is being paced
A pacing cardioverter-defibrillator system may be inserted in a single chamber (pacing in the ventricle) or in dual chambers (pacing in the atrium and ventricle)
Pacing cardioverter-defibrillator pulse generators may be implanted in a subcutaneous infraclavicular pocket or in an abdominal pocket
Removal of a pacing cardioverter-defibrillator pulse generator requires opening of the existing subcutaneous pocket and disconnecting the pulse generator from its electrode(s)
A thoracotomy (or laparotomy in the case of abdominally placed generators) is not required to remove the pulse generator
The electrodes (leads) of a pacing cardioverter-defibrillator system are positioned in the heart via the venous system (transvenously) in most circumstances
However, in certain circumstances an additional electrode may be required to achieve pacing of the left ventricle (biventricular pacing)
In this event, transvenous (cardiac vein) placement of the electrode should be separately reported using code 33224 or 33225
Epicardial placement of the electrode should be separately reported using code 33202-33203
The appropriate codes should be used in addition to the thoracotomy or endoscopic epicardial lead placement codes to report the insertion of the generator if done by the same physician during the same session
Epicardial Lead Placement
Electrode positioning on the epicardial surface of the heart requires thoracotomy, or thoracoscopic placement of the leads
Removal of electrode(s) may first be attempted by transvenous extraction
However, if transvenous extraction is unsuccessful, a thoracotomy may be required to remove the electrodes
Use the appropriate codes in addition to the thoracotomy or endoscopic epicardial lead placement codes to report the insertion of the generator if done by the same physician during the same session
Removal of a permanent epicardial pacemaker and electrodes is performed via thoracotomy
Codes 33236-33238 describe the removal of a pacemaker pulse generator and pacing electrodes via thoracotomy for epicardial single-chamber systems, epicardial dual-chamber systems, or permanent transvenous electrode systems
Removal of a single-lead system (33236) requires exposure of a small area of the heart
Removal of a dual-lead system (33237) usually requires more extensive exposure
The procedure described by code 33238 is used in cases in which an infected transvenous lead has to be removed but attempts to remove it by the usual mechanisms (ie, 33234) are unsuccessful
For a failed attempt at transvenous extraction, it would be appropriate to use 33244 52 in addition to code 33238
Electrophysiologic Operative Procedures
Supraventricular arrhythmias originate above the bundle of His
Surgical treatment of atrial fibrillation or flutter may be performed by either open incision (33254-33256) or endoscopic approach (33265-33266)
These families of codes describe the surgical treatment of supraventricular dysrhythmias (no rhythm)
Tissue ablation, disruption, and reconstruction can be accomplished by many methods including surgical incision or through the use of a variety of energy sources (eg, radiofrequency, cryotherapy, microwave, ultrasound, laser)
If excision or isolation of the left atrial appendage by any method including stapling, oversewing, ligation, or plication is performed in conjunction with any of the atrial tissue ablation and reconstruction (maze) procedures (33254-33259, 33265, and 33266), it is considered part of the procedure and not reported separately
Limited operative ablation and reconstruction (33254 and 33265) is the surgical isolation of triggers of supraventricular dysrhythmias by operative ablation that isolates the pulmonary veins or other anatomically defined triggers in the left or right atrium
Code 33254 describes a closed-heart operation for paroxysmal or short-duration atrial fibrillation/flutter using atrial incision(s) and adjunctive ablation techniques that are limited to the left atrium or do not extend to the atrioventricular annulus
Code 33265 describes a closed-heart endoscopic operation for paroxysmal or short-duration atrial fibrillation/flutter using atrial incision(s) and adjunctive ablation techniques that are limited to the left atrium or do not extend to the atrioventricular annulus
Extensive operative ablation and reconstruction (33255, 33259, and 33266) includes both those services included in the limited service description and any additional ablation of atrial tissue to eliminate sustained supraventricular dysrhythmias
To be considered extensive, the procedure must include operative ablation that involves the right atrium, atrial septum, or left atrium in continuity with the atrioventricular annulus
Coronary Artery Bypass Procedures
Coronary artery bypass graft procedures may be reported in three ways, depending upon the type of operation performed

The first two reporting methods require only a single code as follows:

Venous Grafting or Arterial Grafting

A bypass operation performed with only venous grafts

This is reported with a single code from the 33510-33516 series, reflecting the number of distal anastomoses performed
A bypass operation performed with arterial grafts
This is reported with a single code from the 33533-33536 series, with code selection again reflecting the number of distal anastomoses performed
The codes in this series are also used to report coronary artery bypass procedures with a combination of arterial and venous grafts

Combined Arterial-Venous Grafting

Bypass operations performed with a combination of venous and arterial grafts for distal anastomoses

The third reporting method requires the use of two codes:
A code to indicate that both arteries and veins were used (from the 33517-33523 series
the appropriate add-on code should describe the number of distal venous anastomoses used for the bypass)
An arterial graft code to indicate the number of distal arterial anastomoses required for the bypass procedure (from the 33533-33536 series)
Codes in the combined arterial-venous grafting for coronary bypass series are not to be reported alone
The appropriate vein graft code from this series is used in conjunction with a code from the arterial grafting series to completely describe combined arterial-venous grafting for coronary bypass
As indicated by the symbol placed before each code, codes 33517-33523 are add-on codes and exempt from the use of modifier 51
Open Procurement of Graft Material
Open procurement of the saphenous vein graft is included in the description of work for the venous grafting and combined arterial-venous grafting for coronary artery bypass codes and should not be reported as a separate service or cosurgery
Additionally, arterial graft procurement is included in the description of work for the arterial grafting for coronary artery bypass codes and should not be reported as a separate service or cosurgery
Open procurement of these three types of graft material is reported separately as follows:
Upper extremity vein: 35500
Femoropopliteal vein: 35572
Upper extremity artery: 35600
Redo Operations
CPT code 33530 is an add-on code used to report coronary artery bypass or valve reoperation procedures performed more than one month after the original operation
It is not reported alone but is reported in addition to the appropriate code(s) to describe the bypass or valve procedure performed
Component Coding
Many of the procedures in the Cardiovascular System subsection represent vascular interventions using “component coding
” It is impossible to discuss all aspects of vascular services reporting in this chapter, but offered here are fundamental explanations for coding vascular interventional procedures
To facilitate accurate coding, component coding was introduced to the CPT code set
The component system provides flexibility by allowing the freedom to appropriately combine procedural and imaging codes in a variety of ways to accurately describe the actual service rendered without requiring multiple duplicative codes
The proper use of the procedure codes for vascular interventions, both diagnostic and therapeutic, requires knowledge of vascular anatomy, the types of services performed, what is included in each code, and the coding conventions necessary when codes are used in combination
Component coding is differentiated by vascular and nonvascular interventional procedures and allows for the proper description of image-guided procedures

It allows for the following:

Component coding allows for the flexibility of combining a diagnostic and a therapeutic examination on the same occasion without overstating or understating the services provided

Accurate reporting when one or multiple providers perform different services to provide the total service
Accurate tracking of professional services for outcome analysis, utilization review, and billing purposes
Tracking and reporting of interventional radiological hospital services in a manner identical to that of other surgical and radiological services
Fair relative valuation of similar types of services without regard to the specialty of the providerTo properly code catheterizations, the puncture site(s), vascular family or families, and final catheter position(s) must be known

Interventional Coding Conventions
For procedures reported using component codes, the surgical components of the service are described by the codes listed outside the 70000 series
The radiological or imaging services are described by 70000 series RS&I codes or the 90000 vascular ultrasound codes
Typically, one physician performs the entire interventional procedure, providing both the surgical component(s) and the imaging RS&I component(s)
To completely describe the services rendered, the physician would report both the codes describing the surgical service and the imaging RS&I
Frequently, one provider performs the surgical component(s)and another performs the imaging RS&I component(s)
In these instances, the physician performing the surgical component(s) reports the code(s) outside the 70000 series, whereas the physician responsible for the imaging RS&I reports the appropriate procedure code(s)from the 70000 series
Vascular Injection Procedures
All vascular procedures, whether diagnostic or therapeutic, begin with establishing vascular access (vascular catheterization)
The codes available for reporting the catheterization portion of the procedure are found in the Vascular Injection Procedures series of codes (36000 series)
To code catheterization procedures correctly, it is necessary to become familiar with the anatomy of the vascular system
Primary vessels branch off the aorta
When the primary vessels branch out, these branches are secondary branches, and as the secondary branches split, there are tertiary branches, etc
In the arterial system, catheter placement in a primary branch is described as a first order catheterization
The first order vessel is defined as selective catheterization of the first major branch off the main vessel (aorta)
Nonselective arterial catheterization codes include 36100, 36120, 36140, 36147, 36148, 36160, and 36200
Selective arterial catheterization codes include 36215, 36216, 36217, 36218, 36245, 36246, 36247, and 36248
Selective catheterization of a secondary branch is a second order catheterization, etc
A second order vessel is defined as a catheterization of the first major branch off a first order vessel
Likewise, a third order branch is the catheterization of a first major branch off a second order vessel
Each artery belongs to a vascular family, which is defined as a group of vessels (arteries) fed by a primary branch of the aorta or a primary branch of the vessel punctured

The five vascular systems considered for component coding are as follows:

Systemic arterial
Systemic venous
Pulmonary
Portal
Lymphatic
Noncoronary vascular catheterization procedures are reported either using selective or nonselective catheter placement codes

Selective catheter placement involves more physician work and effort than nonselective catheterizations and increases complication risk to the target vessels
Selective catheterization typically involves the exchange of the catheter to a more flexible device that can be moved, manipulated, or guided into a part of the arterial system other than the aorta or the vessel punctured (usually under fluoroscopic guidance), most often using a guidewire
Nonselective catheter placement means the catheter or needle is placed directly into the major arterial conduit (not moved or manipulated farther into a branch) or is delivered only into the aorta (thoracic and abdominal) from any approach (puncture site)
A nonselective catheter placement is not coded in addition to a selective catheter placement when a single access (puncture) is used
Even if a nonselective catheter placement is performed first, the highest selective placement with each vascular family is the determining factor for the level of coding
This vessel may or may not be the most distal in absolute distance from the puncture site or the origin of the primary vessel
All lesser-order catheter placements in the same vascular family performed for the most selective catheter position to be achieved are included in the higher-order catheterization code
Even if a nonselective catheter placement is performed first, the highest selective placement with each vascular family is the determining factor for the level of coding
2
Which range of codes are selective and which are nonselective catherizations?
Frequently Asked Questions
What is the highest-order selective catheterization when a left middle cerebral catheterization is performed from a femoral artery approach?
Only the highest-order (third-order selective) code 36217 is reported for this scenario
The primary branch of the thoracic aorta is the left common carotid, the secondary branch is the left internal carotid, and the tertiary branch is the middle cerebral artery
If the catheter is pulled back into the common carotid or the proximal internal carotid and proximal internal carotid and the cervical left carotid is studied, the first- or second-order code is not used because the work of getting the catheter to this point would be included in the third-order selective code
What if additional second- or third-order arterial catheterizations are performed in the same vascular family?
If more than one second- or third-order branch in a given vascular family is catheterized, the additional branch catheterization should be described by the use of add-on code 36218 (each additional second-, third-, or higher-order artery, thoracic or brachiocephalic branch) or add-on code 36248 (each additional second-, third-, or higher-order abdominal, pelvic, or lower extremity artery branch)
If multiple selective catheterizations are performed in different vascular families, the highest level of selectivity is reported for each vascular family
In the example given in the previous question, if the catheter was positioned into the left middle cerebral artery, 36217 is coded as described above
If the catheter is pulled back and then used to select the left external carotid artery and a selective external carotid arteriogram is performed, 36218 is coded as well, denoting an additional second-order selective catheterization in the same vascular family (left common carotid vascular family)
Additional second-, third-, and higher-order arterial catheterizations within the same vascular family include 36218 and 36248
What if an additional vascular family is catheterized (ie, the left common carotid artery)?
If either the right internal carotid artery or middle cerebral artery is catheterized, then 36217 is used
This includes the more proximal arteries for the middle cerebral (including the common carotid and internal carotid)
However, if the left common carotid artery is catheterized (an additional vascular family), a separate code with the highest-order catheter location in the additional family is reported
Code 36216 is also reported for this scenario
What if more than one puncture site access is performed?
If two separate access procedures (two different punctures) are performed, each is treated separately for coding purposes
For example, if a nonselective catheter placement from one femoral artery puncture (ie, for an abdominal aortogram) and then a third-order selective catheterization from the contralateral femoral artery puncture are performed, then the nonselective code 36200 should be reported for the aortic catheter and 36247 for the third-order abdominal selective catheterization from the other puncture
(The second puncture should be clearly documented
) It is appropriate to add a modifier (eg, 59) to 36200 to indicate that a separate access/distinct procedure was performed
Are venous catheterizations described as selective and nonselective?
Yes
Venous catheterizations can be described as selective (requiring additional movement or manipulation of the catheter) or nonselective (direct placement of a catheter)
The same vascular family concept as arterial procedures is used to describe venous catheterizations
Determination of first or second order is dependent upon the vein punctured
A venous vascular family includes a first-order vein and all of its secondary branches
There are no codes for each additional second-, third-, or higher-order catheterization in the venous system
Therefore, the codes may be reported again to describe the total number of separate catheterizations performed (eg, 36011 with two units)
How is pulmonary angiography reported in the absence of diagnostic cardiac catheterization?
Pulmonary catheterization procedures may be performed independent of right heart catheterizations and the pulmonary angiography performed at that time (eg, 93501, 93541)
There are only two vascular families: the right and left pulmonary arteries
Code 36014 or 36015 would be reported with modifier 50 appended to most correctly describe right and left pulmonary angiograms performed, because catheter placements were performed in both the right and left pulmonary arteries
Pulmonary angiography codes include 36013, 36014, and 36015
Aneurysm Repair Procedures
The Cardiovascular System subsection of Surgery in the CPT codebook includes four families of codes describing the various techniques for aneurysmal repair
An aneurysm is an abnormal bulging of a vessel, usually due to a weakness or thinning of the vessel wall at that location, caused by congenital or acquired weakness of the vessel wall
Because emergent treatment of ruptured aneurysms carries a very high morbidity and mortality rate, the obvious solution is to treat them electively before rupture
Open Aneurysm Repair
Codes 35001-35152 describe the traditional method for treating aneurysms by direct (open surgical) repair of an aneurysm, pseudo-aneurysm, ruptured aneurysm, and associated occlusive disease directly at the aneurysm site (eg, abdominal aorta, hepatic, celiac, renal, iliac, subclavian artery)
Codes 35001-35152 are reported in the absence of any aneurysmal dilation in the presence of occlusive disease (ie, atherosclerotic plaque) causing diminished blood flow
For direct vessel repairs associated with occlusive disease only, codes 35201-35286 should be reported
Code choice is dependent upon the anatomic site of the vessel and the type of repair performed
The target zone is the region within the vessel where the endoprosthesis is intended to be deployed
Endovascular Aneurysm Repair
Different methods now exist that do not require open dissection of the abdominal aorta to accomplish the repair
Endovascular aneurysm repair involves placing a prosthetic graft within the aneurysm to completely exclude the aneurysm sac from the general circulation
Placement involves the use of both surgical and catheter-based skills and technologies
Compared with conventional repair, the endoluminal approach is less invasive because it eliminates the need for laparotomy and cross-clamping of the aorta and iliac artery
Although the end product of traditional and endovascular abdominal aortic aneurysm (AAA) repair is the same, the devices and techniques are entirely dissimilar
When applying the concepts of component coding to endovascular repair of abdominal and thoracic aortic and iliac artery aneurysms, be careful not to confuse the use of the term component when reporting these procedures
Component coding refers to the use of multiple codes to describe various procedures performed
Unrelated to component coding, the prosthetic device placed to accomplish aneurysm treatment may have one or more components or modules
This example describes application of component coding for endovascular aneurysm repair
The CPT codes for endovascular repair of abdominal and thoracic aortic and iliac artery aneurysms reflect the various stages or steps in the procedure with device-specific codes for prosthesis placement
Often, a team approach is used in performing these procedures
Step-by-step coding allows for accurate coding in which skills of multiple physicians may be necessary, allowing each physician to report those services he or she performed
Whereas a single operator within the team may perform all aspects of a distinct portion of the procedure, other components of the procedure may be performed with the operators working in concert as co-surgeons
To assist in understanding how multiple codes are required to report endovascular aneurysm repair, Figure 4-59 is provided as an example of the steps typically involved in abdominal aneurysm repair(under normal circumstances)

FIGURE 4-59 Typical Steps of AAA Repair

Endovascular Abdominal Aneurysm Repair

Codes for open surgical exposure of the femoral arteries (less often the iliac arteries)
Codes for RS&I
Introduction of catheters/guidewires
Primary repair codes
Codes for extension prostheses
Codes that identify less commonly performed but separately reportable maneuvers/interventional procedures
Codes that identify “conversion” surgery
FIGURE 4-60 Endovascular Repair of AAA

All balloon angioplasty and/or stent deployment within the target treatment zone for the endoprosthesis, either before or after endograft deployment, for any reason, are not separately reportable

This example describes catheter introduction into the aorta or an aortic branch (renal artery)
The introduction of catheters is reported separately in addition to device placement and should be reported according to regular coding conventions for catheterization procedures (see guidelines included in the CPT codebook for vascular injection procedures for more information regarding use of catheterization codes)

Examples of catheterization codes may include the following:

Aorta alone (no selective catheterization): 36200
Aorta bilateral (identifies accessing aorta via both legs): 36200 with modifier 50 appended
Aorta and renal artery via different access points (both legs): 36200 and 36245

If the procedure requires extensive repair or replacement of an artery, this should also be reported separately (eg, 35226, 35286)

How to differentiate the types of prostheses placed in the procedures described by codes 34802 and 34803?
The primary differences between the procedures described are the configuration, length, and shape of the prosthesis required for effective aneurysm treatment
To compare the procedures described by 34802 and 34803, both procedures use modular components that attain an inverted-Y-shape following complete deployment
The primary difference between the procedures is the number of modular components that make up the device
The prosthesis repair procedure described by code 34802 involves two separate pieces that are joined inside the patient’s body during placement, with the main body prosthesis component extending into the ipsilateral iliac artery and creating a distal seal
Code 34803 involves three components that are joined inside the patient during the procedure
Other Procedures
In some circumstances, in addition to placing endovascular graft component(s), the repair provided may require placement of an occlusion device to close an iliac artery
This procedure is identified by the add-on code 34808
In addition, to provide revascularization of the leg vessels that arise from the occluded iliac limb, a femoral-femoral bypass may be performed
When performed as part of an endorepair, the code for a femoral-femoral bypass graft is unique (34813)
This additional bypass is separately reported using the add-on code 34813
Because these are add-on codes, they should only be reported in addition to other repair services
Endovascular Repair of Descending Thoracic Aorta
Codes 33880-33891 represent a family of procedures to report placement of an endovascular graft for repair of the descending thoracic aorta differentiated by the coverage (33880) or noncoverage (33881)of the subclavian artery
Endovascular prostheses for the descending aorta are obtained in modules
The first component of the endovascular repair is deployed such that the leading edge arrives in a nearly normal segment of the proximal aorta, allowing firm fixation
Subsequently, components are deployed through the diseased portion of aorta such that each partially overlaps the preceding one to prevent any leaks between the modules
The components are “tiled” in this fashion until the diseased portion of aorta is completely covered, and the distal-most component lies in normal aorta
Repairs may require one, two, three, or more modules, depending on the diseased descending thoracic aorta
These codes include all device introduction, manipulation, positioning, deployment, and ballooning/stenting done within the endograft
The codes for endovascular repair of an aneurysm of the descending thoracic aorta are also intended to be used as component codes (to identify the specific services provided for the repair performed)

These codes can be separated into the following six groups:

Codes 33880 and 33881 include placement of all distal extensions, if required, in the distal thoracic aorta, whereas proximal extensions, if needed, are reported separately

Open surgical exposure of the femoral, iliac, or brachial arteries or abdominal aorta
RS&I
Introduction of catheters/guidewires
Primary repair codes
Extension prostheses
Other interventional procedures separately reportable
Endovascular Repair of Iliac Aneurysm
In many cases, an AAA extends into the iliac artery
Isolated iliac artery aneurysms are less common than aortic aneurysms
In the absence of aortic aneurysm, endovascular repair of iliac artery aneurysm (IAA) involves a minimally invasive technique that eliminates the need for a large abdominal or retroperitoneal incision to expose the aneurysm
The endovascular repair technique involves the access of femoral arteries either percutaneously or with open exposure, with introduction and advancement of a collapsed prosthesis through the iliac artery or arteries in the pelvis
The endograft is then positioned to cover the aneurysm using fluoroscopic guidance
Once in the correct location, positioned exactly across the aneurysm, the device is deployed, expanding the prosthesis to full size
The services that are inherent components of the endovascular IAA repair include balloon dilatation within the endoprosthesis to achieve full expansion of the graft and complete contact of the attachment devices necessary to properly secure the prosthesis
The codes for endovascular repair of an IAA are also intended to be used as component codes (to identify the specific services provided for the repair performed)

These codes can be separated into the following six groups:

Open surgical exposure of the femoral or iliac arteries
RS&I
Introduction of catheters/guidewires
Primary repair codes
Extension prostheses
Other interventional procedures separately reportable

Balloon angioplasty and/or stent deployment performed within the target zone of the endoprosthesis is not reported separately, regardless of whether performed before or after endograft deployment

How to Code Aneurysm Repair
Because a number of methods now exist to perform aneurysm repair, it is important to identify the codes that accurately describe the procedures performed

To address this, it may help to ask the following questions:

Is the procedure an open “direct” aneurysm repair, or is it an endovascular repair?
If an endovascular repair, was there open surgical exposure of an artery?
What catheters were introduced into the aorta or aortic branches for the endovascular repair?
What type of device was used for the endovascular repair?
What RS&I was performed?
Were other separately reportable services provided?
Which physician performed each component, and were some components of the procedure accomplished as cosurgeons or assistant surgeons?
Arteries and Veins: Thromboendarterectomy
Thromboendarterectomy is performed for treatment of severe stenosis of arteries, typically because of atherosclerosis

Severity of disease is related to gender, age, lipid status, family history, presence of diabetes, and tobacco abuse
Codes 35301-35381 describe open thromboendarterectomy procedures
Codes 35301-35306 describe thromboendarterectomy of the distinct vessels of the lower extremities, including the superficial femoral artery, the popliteal artery, the tibioperoneal trunk artery, and the tibial and peroneal arteries
In addition to code 35305 for the initial endarterectomy procedure of the tibial or peroneal branch artery, add-on code 35306 is used to report thromboendarterectomy of each additional tibial or peroneal artery in addition to the initial procedure
It is not appropriate to report code 35500, Harvest of upper extremity vein, 1 segment, for lower extremity or coronary artery bypass procedure, in addition to 35302-35306, because harvest of a vein graft may be necessary to complete the procedure with a patch graft following the removal of plaque and the diseased portions of the artery and is included in this procedure

Vein harvest, if performed, includes the following intraprocedural steps, thus precluding the additional reporting of code 35500:

Shift attention to the vein harvest site—usually predetermined and previously prepped

Incise the skin over the vein
Dissect through the soft tissue to find the vein
Carefully dissect out the vein, tying and dividing all side branches
Check the original operative site to ensure that a sufficient length of vein is exposed
Clamp the vein and excise the segment to be used for the patch
Ligate the transected ends of the vein that remain in the patient
Open and examine the removed segment of the vein on the back table to ensure suitability
Crop the vein to the shape required to serve as a patch
Preserve the vein patch in heparinized saline until it is time to be used
Bypass Graft
Bypass grafts are traditionally described by including the inflow artery and the outflow target artery
Some clinical indications for performing bypass grafts are trauma or severe stenosis of arteries, typically because of atherosclerosis
Severity of disease is related to gender, age, lipid status, family history, presence of diabetes, and tobacco use
Vein
Bypass grafts are traditionally described by including the inflow artery and the outflow target artery
Some clinical indications for performing bypass grafts are trauma or severe stenosis of arteries, typically because of atherosclerosis
Severity of disease is related to gender, age, lipid status, family history, presence of diabetes, and tobacco use
Codes 35501-35571 describe open surgical procedures that involve the use of venous material alone
Certain bypass graft codes from this family are discussed
Code 35501 is reported for performance of bypass graft from the common carotid to the internal carotid on the same side of a person’s neck (ie, a common carotid to ipsilateral internal carotid bypass graft)
Code 35509 is intended to report bypass graft carotid bypass on the opposite side of the neck (ie, carotid-contralateral carotid bypass graft)
Code 35506 describes a carotid-subclavian bypass procedure using vein conduit
Aortoiliac bypass graft with vein (35537) and aortobi-iliac bypass graft with vein (35538) distinguish the effort required to perform each of these procedures
Aortofemoral bypass with vein (35539) and aortobifemoral bypass graft with vein (35540) distinguish the effort required to perform each of these procedures
1
A pacemaker system includes a pulse generator (containing electronics and a battery) and one or more electrodes (leads)
The pulse generator is placed in a subcutaneous pocket created either in an infraclavicular site or underneath the abdominal muscles just below the ribcage
2
Nonselective arterial catheterization codes include 36100, 36120, 36140, 36147, 36148, 36160, and 36200
Selective arterial catheterization codes include 36215, 36216, 36217, 36218, 36245, 36246, 36247, and 36248
Cardiovascular System Exercises
Check your answers in Appendix B
True or False
1
Removal of an existing pacing cardioverter-defibrillator device is not included in the replacement code and should be separately reported
True or False
2
The procurement of an upper extremity vein is included when a coronary artery or lower extremity bypass procedure is reported
True or False
Short Answer
3
How is replacement of a dual-chamber permanent pacemaker and transvenous electrodes with a new dual-chamber permanent pacemaker and electrodes reported?
4
Harvesting of the radial artery for coronary artery bypass procedure is reported with which code(s)?
5
A redo coronary artery bypass graft was performed on a patient involving the left internal mammary artery to the left anterior descending artery and a saphenous vein graft to the right coronary artery
The original coronary artery bypass graft was two years ago
How is this reported?
6
Abdominal aortogram (by catheter in aorta, femoral approach)
How is this reported?
7
Bilateral main (R) and (L) pulmonary arteriograms
How is this reported?
8
For endovascular AAA repair, Physician A performed bilateral femoral artery open exposures
Physician B placed catheters/sheaths into the aorta bilaterally
(Both physicians placed the modular bifurcated prosthesis with two docking limbs
) Physician A closed the cutdowns
Physician B performed RS&I for the procedure
How is this reported?
9
A 54-year-old male underwent aortoiliofemoral arteriography to evaluate an endoleak detected 10 months subsequent to an endovascular aortic aneurysm repair
The angiogram was performed from a left common femoral percutaneous puncture
The diagnostic study confirmed an endoleak, which was a Type I leak from the distal anastomosis in the left common iliac artery
Initially, this was treated with balloon angioplasty to try to achieve a seal at the distal anastomosis, but despite multiple attempts to close the leak with the balloon, the endoleak persisted
To resolve the leak, an extension into the external iliac was required
The hypogastric artery was patent, and selective angiography of the hypogastric artery was done
Based on the findings, it was determined that coil embolization of the hypogastric artery would also be necessary to resolve the leak, so this was done
Final angiography after embolization confirmed good position of the coils with closure of the main trunk of the hypogastric artery
A covered stent extension was then placed from the left limb of the graft into the external iliac, and the anastomoses were secured with balloon angioplasty
Final angiography confirmed that the left limb was now widely patent with no persistent endoleak
Collateral filling was seen into the distal branches of the hypogastric artery, but no retrograde filling was seen into the common iliac artery
The arteriotomy was closed with a percutaneous closure device
How is this reported?
10
A 73-year-old male with hypertension (55-pack-a-year smoking habit and prior myocardial infarction) underwent endovascular repair of the descending thoracic aortic aneurysm nine months ago
On the follow-up CT scan, he was found to have a distal endoleak
Placement of a distal extension was undertaken to seal the leak

How is this procedure reported?

INTRO TO CPT CODING
BOOK II COMPLETE

Cardiovascular System
The Cardiovascular System subsection of the CPT code set contains codes for reporting procedures of the heart and pericardium (see Figure 4-31) and arteries and veins (see Figures 4-32 and 4-33)

This portion of Chapter 4 reviews the CPT guidelines associated with reporting cardiacrelated therapeutic procedures, including transmyocardial revascularization, pacemaker, cardioverter-defibrillator, cardiac hybrid interventions, cardiac assist, transcatheter aortic valve replacement, coronary artery bypass, and operative electrophysiologic procedures
Transmyocardial Revascularization
Transmyocardial laser revascularization is performed on a beating heart to relieve angina
Code 33140 includes a thoracotomy to open the pleural space or a sternotomy with opening of the pericardium
Laser channels are created into the epicardium through the ventricular wall to the ventricular cavity to vaporize tissue
When performed as an adjunct to other cardiac procedures (eg, coronary artery bypass grafts), add-on code 33141 is reported
Code 33141 is used in conjunction with 33400-33496, 33510-33536, and 33542
Pacemaker or Pacing Cardioverter-Defibrillator Guidelines
A pacemaker system includes a pulse generator (containing electronics and a battery) and one or more electrodes (leads)
The pulse generator is placed in a subcutaneous pocket created either in a subclavicular site or underneath the abdominal muscles just below the rib cage
A pacemaker system may be inserted in a single chamber (pacing in the ventricle), in dual chambers (pacing in the atrium and ventricle), or as a biventricular system (pacing in the left and right ventricles)
Electrodes (leads) may be inserted through a vein (transvenous) or placed on the surface of the heart (epicardial)
Epicardial placement of electrodes requires a thoracotomy for electrode insertion
FIGURE 4-31

Cardiac Anatomy

FIGURE 4-32
Circulatory System—Arteries

FIGURE 4-33
Circulatory System—Veins

Types of Pacing Systems
The heart consists of four chambers: the right and left atria and the right and left ventricles

Pacing systems regulate the rate of contraction of the heart muscle within a defective chamber
A single-chamber pacemaker system includes a pulse generator and one electrode inserted in either the atrium or the ventricle
A dual chamber pacemaker system or pacing cardioverterdefibrillator system includes a pulse generator and two electrodes inserted in either the right atrium and ventricle or a combination of the right atrium or right ventricle and coronary sinus to pace the left ventricle
The following definitions apply to codes 33206-33249:
Single lead: a pacemaker or pacing cardioverterdefibrillator with pacing and sensing function in only one chamber of the heart
Dual lead: a pacemaker or pacing cardioverterdefibrillator with pacing and sensing function in only two chambers of the heart
Multiple lead: a pacemaker or pacing cardioverterdefibrillator with pacing and sensing function in three or more chambers of the heart
CODING TIP Pacing in the left and right ventricles requires insertion of an additional electrode (lead) through the coronary sinus (33224 or 33225) into the left ventricle
Therefore, the left ventricular lead may also be referred to as an “LV lead” or a “coronary sinus lead

Pacing Cardioverter-Defibrillator Systems
Similar to a pacemaker system, a pacing cardioverter-defibrillator system includes a pulse generator and electrodes (see Figure 4-34), and may require multiple leads, even when only a single chamber is being paced
A pacing cardioverter-defibrillator system may be inserted in a single chamber (pacing in the ventricle), in dual chambers (pacing in the atrium and ventricle), or as a biventricular system (pacing in the left and right ventricles)
These devices use a combination of antitachycardia pacing, low-energy cardioversion, or defibrillating shocks to treat ventricular tachycardia or ventricular fibrillation
Pacing cardioverter-defibrillator pulse generators may be implanted in a subcutaneous infraclavicular pocket or in an abdominal pocket
Removal of a pacing cardioverter-defibrillator pulse generator requires opening of the existing subcutaneous pocket and disconnecting the pulse generator from its electrode(s)
A thoracotomy (or laparotomy, in the case of abdominally placed pulsed generators) is not required to remove the pulse generator
CODING TIP When epicardial lead placement is performed with insertion of the generator, report 33202, 33203 in conjunction with 33212, 33213, 33221, 33230, 33231, or 33240
The electrodes (leads) of a pacing cardioverterdefibrillator system are positioned in the heart via the venous system (transvenously), in most circumstances
However, in certain circumstances, an additional electrode may be required to achieve pacing of the left ventricle (biventricular pacing)
In this event, transvenous (cardiac vein) placement of the electrode should be separately reported with code 33224 or add-on code 33225
Epicardial placement of the electrode(s) should be separately reported with code 33202 or 33203
(See Figure 4-34
)
Epicardial Lead Placement
Electrode positioning on the epicardial surface of the heart requires thoracotomy, or thoracoscopic placement of the leads
Removal of electrode(s) may first be attempted by transvenous extraction (33234, 33235, or 33244)
However, if transvenous extraction is unsuccessful, a thoracotomy may be required to remove the electrodes (33238 or 33243)
Codes 33212, 33213, 33221, 33230, 33231 or 33240, as appropriate, are used in addition to the thoracotomy or endoscopic epicardial lead placement codes 33202 or 33203 to report the insertion of the generator if done by the same physician during the same session
FIGURE 4-34
Insertion of Epicardial Electrode(s)
Open Incision
CODING TIP Codes 33202 and 33203 also represent left ventricular epicardial lead placement
Change of Pulse Generator (Battery)
When the “battery” of a pacemaker or pacing cardioverter-defibrillator is changed, it is actually the pulse generator that is replaced
Removal of only the pacemaker or pacing cardioverterdefibrillator pulse generator is reported with 33233 or 33241
Removal of a pacemaker or pacing cardioverter-defibrillator pulse generator with insertion of a new pulse generator without any lead replacement or insertion is reported with a code from the 33227-33229 or 33262-33264 series
Code 33212, 33213, 33221, 33230, 33231, or 33240, as appropriate, are reported for insertion of a new pulse generator, when existing leads are already in place and when no prior pulse generator is removed
(See Figure 4-35
)
When a pulse generator insertion involves the insertion or replacement of one or more lead(s), the pacemaker system codes 33206-33208 or the pacing cardioverter-defibrillator code 33249 should be reported
Removal of a pulse generator (33233 or 33241) or extraction of transvenous leads (33234, 33235, or 33244) should be reported separately
An exception involves a pacemaker upgrade from a single to a dual system, which includes removal of the pulse generator, replacement of a new pulse generator, and insertion of a new lead, all reported using 33214
FIGURE 4-35
Removal of Permanent Pacemaker Pulse Generator
Device Replacement
Pulse generator removal and replacement procedures are reported based on the type of the device (pacemaker vs cardioverter-defibrillator) and the type of lead system ultimately inserted (ie, dual, multiple)
In the case of a pacing cardioverter-defibrillator pulse generator replacement when a different system from the existing system is inserted, code selection should be based on the final lead system inserted (33263, 33264)
Similarly, a permanent pacemaker system removal with replacement of a permanent pacemaker pulse generator would be reported using a code from the 33227-33229 series
In summary, codes 33227-33229 require insertion and removal of the same type of device (ie, pacemaker system)
It would not be appropriate to report a code from the 33227-33229 series if removing a pacemaker and inserting an implantable cardioverter-defibrillator system
Similarly, codes 33262-33264 require insertion and removal of the same type of device (ie, pacing cardioverterdefibrillator system)
It would not be appropriate to report a code from the 33262-33264 series if removing a pacemaker and inserting an implantable cardioverter-defibrillator system
CODING TIP Definition of a multiple lead device is a pacemaker with pacing and sensing function in 3 or more chambers of the heart
In most circumstances, the electrodes of a pacing cardioverter-defibrillator system are positioned in the heart via the venous system (transvenously)
Removal of the electrode(s) may first be attempted by transvenous extraction, described by code 33244
If transvenous extraction is unsuccessful, a thoracotomy may be required to remove the electrodes (as described by code 33243)
CODING TIP Codes 33206-33208 should not be reported in conjunction with codes 33227-33229 when the sole procedure is replacement of a pacemaker pulse generator and the procedure does not involve insertion or replacement of right atrial and/or ventricular electrode(s)
Repositioning
Repositioning of a previously placed right atrial or right ventricular electrode is reported with code 33215
Code 33215 applies to single- and dual-chamber pacemaker or pacing cardioverterdefibrillator systems
Repositioning of a left ventricular pacing electrode is reported with code 33226
Electrophysiologic Services
The pacemaker and pacing cardioverterdefibrillator device evaluation codes 93279-93299 may not be reported in conjunction with pulse generator and lead insertion or revision codes 33206-33249
Defibrillator threshold testing (DFT) during pacing cardioverter-defibrillator insertion or replacement may be separately reported using 93640, 93641
(Refer to Chapter 7 for further discussion of reporting electrophysiologic services
)
Radiological Supervision and Interpretation
Radiological supervision and interpretation related to the pacemaker or pacing cardioverterdefibrillator procedure is included in codes 33206-33249
To report fluoroscopic guidance for diagnostic lead evaluation without lead insertion, replacement, or revision procedures, use 76000
Surgical Creation of a Pocket for Pulse Generator (Use of Modifier 62)
CODING TIP Surgically creating a pocket for the pulse generator is included when the codes for pacemaker and defibrillator procedures are reported
Surgical creation of a pocket for the pulse generator is included when the codes for pacemaker and pacing cardioverter-defibrillator procedures are reported
Use of modifier 62 becomes necessary when two physicians participate as primary surgeons during the single procedure
If one physician creates the pocket and a second physician inserts the device, each physician should report his or her distinct operative work by appending modifier 62, two surgeons, to the single definitive procedure code
EXAMPLE
Physician A performs the surgical creation of the pocket for the pulse generator
Physician B inserts a permanent pacemaker with transvenous atrial and ventricular electrodes
The following codes would be reported:
Physician A:
33208-62
Physician B: 33208-62
Each physician should separately document his or her involvement in the performance of the single definitive procedure performed
This documentation should be submitted when the claim is filed with the insurance company
(Refer to Chapter 8 for further discussion regarding the use of modifier 62
)
Now that the various guidelines for reporting the pacemaker or pacing cardioverter-defibrillator codes have been reviewed, the codes in this section of the CPT code set will be addressed
Pacemaker Insertion or Replacement
Permanent pacemakers are most commonly inserted by means of a transvenous approach, described by codes 33206-33208
These codes include the subcutaneous insertion of the pulse generator and transvenous placement of electrode(s) specific to the chamber of the heart in which the transvenous leads are positioned (atrial
ventricular
atrial and ventricular)
All three approaches require surgical creation of a pocket for placement of the pulse generator
The use of the word replacement in the 33206-33208 code series is not meant to imply that the removal of an existing device is included in the replacement procedure
Codes 33206-33208 refer to the insertion of a new or replacement of the entire system, including the lead(s) and pulse generator
Code 33206 is used to report the insertion of a new or replacement of a permanent pacemaker system using a transvenous atrial electrode
Code 33207 is used to report the insertion of a new or replacement permanent pacemaker system employing a ventricular electrode
Code 33208 is used to report the insertion of a new or replacement transvenous permanent pacemaker system employing both an atrial and a ventricular electrode
CODING TIP For removal and replacement of pacemaker pulse generator and transvenous electrode(s), use code 33233 in conjunction with either 33234 or 33235 and codes 33206-33208
Insertion or Replacement of Temporary Transvenous Pacemaker or Electrode
Code 33210 is used to report the insertion or replacement of a single temporary transvenous pacing catheter, atrial or ventricular
Code 33211 is used to report the insertion or replacement of two temporary transvenous pacing catheters, atrial and right ventricular
These pacing catheters are then attached to an external pulse generator
Note that both these codes have the separate procedure designation
(See Figure 4-36
)
CODING TIP There is currently no code for the infrequently performed insertion of a transthoracic pacing electrode
Code 33999, Unlisted cardiac procedure, should be reported if this procedure is performed
For temporary transcutaneous pacing, see code 92953
FIGURE 4-36
Temporary Pacemaker
Insertion or Replacement of Pacemaker Pulse Generator
Codes 33212, 33213, and 33221 are used to report only the insertion of the pacemaker pulse generator
The code selection is based upon whether one, two, or multiple existing leads are reconnected to the pulse generator and tested for pacing and sensing parameters
In each instance, the pacemaker pocket is surgically re-entered, the pulse generator is disconnected from the lead(s), which is/are tested to verify proper functioning, and the new pulse generator is attached and placed in the pacemaker pocket
CODING TIP Codes 33212, 33213, 33221 are not to be reported in conjunction with 33233 or 33227-33229 for removal or removal with replacement of a pacemaker pulse generator
Upgrade of Implanted Permanent Pacemaker System
Code 33214 is used to report the conversion of an implanted pacemaker system from a single-chamber to a dual-chamber system
This most commonly applies to circumstances in which a dual-chamber pacing system has been deemed better suited for a patient after the original single-chamber pacing implant (eg, a patient demonstrating pacemaker syndrome)
This code includes removal of the previously placed pulse generator, testing of the existing lead, insertion of a new lead, and insertion of a new dual-chamber system pulse generator
If a left ventricular lead is also inserted at the time of the upgraded system, code 33225 may also be reported
Repositioning of Previously Implanted Pacemaker or Pacing Cardioverter-Defibrillator
Code 33215 is used to report repositioning of a previously implanted right atrial or right ventricular transvenous pacemaker or pacing cardioverter-defibrillator electrode
This code may be used to report repositioning of electrodes implanted for either single- or dual-chamber systems and may be reported at any time after the initial placement of the electrode
The appropriate modifier (eg, modifier 59 for the same date of service or modifier 76, 77, or 78, as appropriate) should be appended when repositioning is performed within the postoperative period
Insertion of Transvenous Electrode(s): Permanent Pacemaker or Cardioverter-Defibrillator System
Codes 33216 and 33217 describe the insertion of a single transvenous electrode or the insertion of two transvenous electrodes for either a permanent pacemaker or cardioverter-defibrillator system
If transvenous removal of electrode(s) is performed at the time of insertion, code 33234 for a pacemaker system or 33244 for a pacing cardioverter-defibrillator system may also be reported
CODING TIP Do not report 33216-33217 in conjunction with 33214
Transvenous Electrode Repair
Codes 33218 and 33220 describe repair (eg, splicing a fracture, modifying a terminal pin, repairing insulation) of one or two transvenous permanent pacemaker(s) or pacing cardioverterdefibrillator electrode(s) without replacement of the pulse generator
For repair of two transvenous electrodes for a permanent pacemaker or pacing cardioverter-defibrillator with replacement of the pulse generator, use codes 33228, 33229, or 33263, 33264, and 33220
CODING TIP Code 93640 or 93641 should be reported in addition to 33223, 33230, 33231, and 33240 for defibrillator threshold (DFT) testing performed at the time of a pulse generator implant
Revision or Relocation of Pulse Generator Skin Pocket
Relocation of a skin pocket for a pacemaker (33222) or cardioverter-defibrillator (33223) is necessary for various clinical situations such as infection or erosion
The relocation may be performed as a stand-alone procedure such as relocation of an existing pulse generator or relocation may be necessary at the time of a pulse generator or electrode insertion, replacement, or repositioning
When performed at the time of an initial pulse generator insertion, the skin pocket creation is an integral part of the procedure and not separately reported
Code 33223 describes relocation of a defibrillator generator skin pocket of a pacer system
When skin pocket relocation is performed as part of an explant of an existing generator followed by replacement with a new generator and creation of a new skin pocket, the pocket relocation should be separately reportable as it involves making a new fresh incision in a new, different site of the body
The skin pocket relocation also involves the formation of a new subpectoral or prepectoral pocket for the new generator to be placed
Therefore, the pocket relocation is additional work not included in the pulse generator removal and replacement procedures
Codes 33206, 33207, 33208, 33212, 33213, 33214, 33221, 33225, 33227, 33228, 33229, 33230, 33231, 33233, 33240, 33241, 33249, 33262, 33263, or 33264, as appropriate, may be reported in addition to skin pocket relocation codes 33222 or 33223 when removal and/or replacement of a pulse generator is performed
The relocation of a skin pocket involves tunneling of leads to the new site
When an existing lead requires replacement, repair, or repositioning, this procedure is not a typical component of a relocation of a skin pocket
Therefore, when performed, the lead replacement, repair, or repositioning code 33222 or 33223 may be reported in addition to 33215, 33216, 33217, 33218, 33220, 33224, 33226, 33234, 33235, 33236, 33237, 33238, 33243, or 33244
Revision of a skin pocket is included in codes 33206-33249, 33262-33264
When revision of a skin pocket involves incision and drainage of a hematoma or complex wound infection, Integumentary System code 10140 or 10180 may be reported
For debridement of subcutaneous tissue, muscle and/or fascia at the skin pocket, code 11042, 11043, 11044, 11045, 11046, or 11047, as appropriate, may be reported
If complex wound repair is performed, code 13100, 13101, or 13102 may be reported
Insertion or Repositioning of Cardiac Venous System (Left Ventricular/Coronary Sinus) Pacing Electrode
In certain circumstances, an additional electrode may be required to achieve pacing of the left ventricle (biventricular pacing)
The implant procedure for the biventricular system is similar to that of a single- or dual-chamber system, with the additional complexity of the transvenous placement of the lead in a cardiac vein to reach the left ventricle
Implantation of a biventricular system requires a coronary guide catheter and the use of venography (not separately reported) to guide the lead through the coronary sinus and into a cardiac vein for placement in the left ventricle
CODING TIP A left ventricular pacing catheter may be referred to as either a biventricular lead or a coronary sinus lead
Codes 33224-33226 are used to report lead placement procedures in the cardiac venous system of the left ventricle to achieve biventricular pacing (see Figure 4-37)
This technique differs greatly from the simple, direct-lead positioning used for pacing of the right atrium or ventricle
Insertion of a left ventricular pacing electrode uses a transcatheter technique that provides access through the coronary sinus into a cardiac vein
Accurate placement of the electrode requires the use of venography to identify and map the cardiac venous system prior to placement of the lead
Epicardial placement of the electrode should be separately reported with code 33202 or 33203 (see Figure 4-37)
CODING TIP Code 33225 should never be reported as a stand-alone code, because of its designation as an add-on code
Code 33224 is used to report the insertion of a pacing electrode into the cardiac venous system for left ventricular pacing and includes attachment to a previously placed pacemaker or pacing cardioverter-defibrillator pulse generator
Revision of the pacemaker pocket and removal, insertion, and/or replacement of an existing pulse generator are included in the procedure, if performed
Re-insertion of the existing pulse generator is inherent in 33224
When epicardial electrodes are inserted at the same session, code 33224 should be reported in addition to code 33202 or 33203
Code 33225 is an add-on code that is reported in addition to 33206, 33207, 33208, 33212, 33213, 33214, 33216, 33217, 33221, 33228, 33229, 33230, 33231, 33233, 33234, 33235, 33240, 33249, 33263, or 33264 when insertion of a left ventricular pacing electrode is performed at the time of insertion of a pacing cardioverterdefibrillator or pacemaker pulse generator
Code 33226 is used to report repositioning of a previously implanted cardiac venous system left ventricular pacing electrode
This code also includes revision of the pacemaker pocket and removal, insertion, and/or re-insertion of an existing pulse generator and may be reported at any time after the initial placement of the electrode
The appropriate modifier (eg, modifier 59 for the same date of service, or modifier 76, 77, or 78, as appropriate) should be appended when repositioning is performed within the postoperative period
FIGURE 4-37
Biventricular Pacing: 33224-33226
Removal Procedures
Code 33233 describes removal of only a permanent pacemaker pulse generator (see Figure 4-35)
When performing removal of a pulse generator, it is not appropriate to report codes 33227-33229 in conjunction with 33233
Codes 33234 and 33235 are used to report removal of transvenous pacemaker electrode(s) from a single-lead system with atrial or right ventricular lead placement (33234) and removal of transvenous electrode(s) from a dual-lead system (33235)
The method of extraction is not specified and can be either by simple traction or with snare or extraction devices
There is no specific CPT code for reporting the removal of more than two pacemaker leads
CODING TIP For pacemaker pulse generator replacement only, code 33233 is reported in addition to code 33212 for an existing single lead or code 33213 for existing dual leads
Codes 33236, 33237, and 33238 describe thoracotomy as the surgical approach for the removal of a pacemaker pulse generator and pacing electrodes of an epicardial single-chamber system (33236) or epicardial dual-chamber system (33237), and the removal of permanent transvenous electrodes (33238)
Removal of a single epicardial lead system (33236) requires exposure of a small area of the heart
Removal of a dual epicardial lead system (33237) usually requires more extensive exposure
The procedure described by code 33238 is used in cases in which an infected transvenous lead has to be removed but attempts to remove it via the usual mechanisms (ie, 33234) are unsuccessful
For a failed attempt at transvenous extraction, it would be appropriate to use 33234 (with modifier 52, Reduced services, appended) in addition to code 33238
Insertion, Replacement, or Removal of Pacing Cardioverter-Defibrillator Pulse Generator or Electrode(s)
Codes 33230, 33231, 33240, and 33241 are used to report the techniques used for insertion, removal, or repair of an implantable cardioverter-defibrillator generator single-, dual-, or multiple-lead system
Implantable cardioverterdefibrillators can be inserted by using an open surgical approach (eg, sternotomy or thoracotomy) or a transvenous approach for insertion of electrodes
Codes 33230, 33231, and 33240 are used to report insertion of only a pulse generator based on the number of existing lead(s)
If an existing pulse generator is removed and replaced, code 33230, 33231, or 33240 is not reported in conjunction with 33241 for removal of the pulse generator
Code 33230, 33231, or 33240 is also not reported in addition to codes 33262-33264 for removal with replacement of the pacing cardioverter-defibrillator pulse generator
Code 93640 or 93641 should be reported in addition to 33223, 33230, 33231, 33240 defibrillator threshold (DFT) testing performed at the time of a pulse generator implant
Code 33240 is used to report the insertion of a single lead- or pacing cardioverter-defibrillator pulse generator
This code may be reported for insertion of a new pulse generator or replacement of a previously placed device
If the pulse generator is replaced (ie, removal of an existing pulse generator and insertion of a new generator), then code 33241 may be additionally reported with 33240 to represent the removal of the existing implantable cardioverter-defibrillator pulse generator
Code 33241 is used to report the subcutaneous removal of only the pacing cardioverterdefibrillator pulse generator
Because the pulse generator is located outside the thoracic cavity (eg, in a pocket under the abdominal muscles), the removal does not require a thoracotomy
Removal and replacement of a pacing cardioverter-defibrillator pulse generator and electrode(s) is reported with 33241 in conjunction with either 33243 and 33249, or 33244 and 33249
Code 33243 is reported for the removal of pacing cardioverter-defibrillator electrode(s) by thoracotomy or sternotomy
With current technology, only the electrode system may need to be removed by thoracotomy
Therefore, subcutaneous removal of a pulse generator is reported using 33241, and the electrode system removal by open thoracotomy is additionally reported using 33243
Code 33244 is reported for the removal of a pacing cardioverter-defibrillator electrode(s) by transvenous extraction
Rather than creating a thoracotomy incision, the lead is removed through the blood vessel
Because transvenous extraction is not always successful, a failed attempt at transvenous extraction followed by removal by thoracotomy would be reported with code 33244 appended by modifier 52, Reduced services, and code 33243
Code 33249 is used to report the replacement of transvenous electrode lead(s) for a single- or dual-chamber pacing cardioverter-defibrillator and insertion of the pulse generator by other than a thoracotomy approach
For the removal and replacement of a pacing cardioverter-defibrillator system (pulse generator and electrodes), report 33241 and 33243, or 33244 and 33249, as appropriate
Codes 33262-33264 describe removal with replacement of a pacing cardioverter-defibrillator pulse generator
Code 33262 specifies a single-lead system
code 33263 specifies a dual-lead system
and code 33264 specifies a multiple-lead system
Code selection should be based on the final lead system inserted
EXAMPLE
A pacing cardioverter-defibrillator pulse generator dual-lead system is removed and a multiple-lead system is inserted
The following code is used to report this procedure:
Code 33264 should be reported for the multiple-lead system because that code represents the final lead system inserted
Electrophysiologic Operative Procedures
Supraventricular arrhythmias originate above the bundle of His
Surgical treatment of atrial fibrillation or flutter may be performed by either open incisional (33254-33256) or endoscopic (33265-33266) approach
These families of codes refer to combinations of surgical and electrophysiologic (radiofrequency, cryotherapy, microwave, ultrasound, laser) techniques to place lesions that interrupt the intra-atrial reentrant pathways that support dysrhythmias (no rhythm) to create a mazelike pathway for sinus activation of the atria and the atrioventricular (AV) node
Any of the surgical methods described are utilized to create the new impulse pathways, in which excision or isolation of the left atrial appendage is accomplished
Stapling, oversewing, ligation, or plication are included and not separately reported
Codes 33250 and 33251 are used to report the surgical ablation of arrhythmogenic foci for supraventricular arrhythmias with (33250) or without (33251) cardiopulmonary bypass
CODING TIP Codes 33254, 33255, and 33256 should not be reported with codes for cardiac and intracardiac tumor removal, valve procedures, coronary artery repairs, coronary bypass graft procedures, and cardiac anomaly, aortic aneurysm, and pulmonary artery repairs
If excision or isolation of the left atrial appendage by any method, including stapling, oversewing, ligation, or plication, is performed in conjunction with any of the atrial tissue ablation and reconstruction (maze) procedures (33254-33259, 33265, and 33266), it is considered part of the procedure and not separately reported
The appropriate atrial tissue ablation add-on code (33257, 33258, 33259) should be reported in addition to an open cardiac procedure requiring sternotomy or cardiopulmonary bypass if performed concurrently
Limited operative ablation and reconstruction (33254 and 33265) involves surgical isolation of supraventricular dysrhythmia triggers in the left or right atrium
Code 33254 describes a closed-heart operation for paroxysmal or short duration atrial fibrillation/flutter, using atrial incision(s) and adjunctive ablation techniques that are limited to the left atrium or do not extend to the AV annulus
Code 33265 describes a closed-heart, endoscopic operation for paroxysmal or short-duration atrial fibrillation/flutter, using atrial incision(s) and adjunctive ablation techniques that are limited to the left atrium or do not extend to the AV annulus
Extensive operative ablation and reconstruction (33255, 33256, and 33266) include both those services included in the “limited” service description and any additional ablation of atrial tissue to eliminate sustained supraventricular dysrhythmias
To be considered extensive, the procedure must include operative ablation that involves the right atrium, the atrial septum, or left atrium in continuity with the AV annulus
CODING TIP The insertion of temporary cardiac electrode or pacemaker catheters, thoracotomy, and thoracostomy are included in 33254-33256 and not separately reported
Code 33255 describes a closed-heart operation for chronic atrial fibrillation or flutter, Cox maze III or variation, atrial incision(s), and adjunctive ablation techniques that include extensive lesion sets and annular lesions
Only 33256 is reported if cardiopulmonary bypass is performed in addition to the maze procedure
Code 33253 was extensively revised and renumbered to code 33256
Code 33266 describes a closed-heart endoscopic operation for chronic atrial fibrillation or flutters, Cox maze III or variation, atrial incision(s), and adjunctive ablation techniques that include extensive lesion sets and annular lesions
Patient-Activated Event Recorder
Codes 33282 and 33284 describe the implantation and removal of an insertable loop recorder device that extends the cardiac monitoring period sufficiently to evaluate infrequent, recurrent symptoms
The implantation (33282) includes the initial programming of the device
For subsequent or periodic electronic analysis, as well as any necessary reprogramming, 93285, 93291, or 93298 is used
CODING TIP For subsequent or periodic electronic analysis and/or reprogramming of a patient-activated event recorder, 93285, 93291, 93298, or 93299 is used
Cardiac Valve Procedures
Codes 33361-33366 and 0318T are used to report transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve implantation (TAVI)
TAVR or TAVI requires two physician operators, and all components of the procedure are reported using modifier 62
(Refer to Chapter 8 for further information related to the use of modifier 62)
Codes 33361-33366 and 0318T include the work, when performed, of percutaneous access, placing the access sheath, balloon aortic valvuloplasty, advancing the valve delivery system into position, repositioning the valve as needed, deploying the valve, temporary pacemaker insertion for rapid pacing (33210), and closure of the arteriotomy when performed
Codes 33362-33366 also include open arterial or cardiac approach
Angiography, radiological supervision, and interpretation performed to guide TAVR or TAVI are included in these codes (eg, guiding valve placement, documenting completion of the intervention, assessing the vascular access site for closure)
CODING TIP Transcatheter aortic valve replacement (TAVR)/transcatheter aortic valve implantation (TAVI) requires two physician operators, and all components of the procedure are reported with modifier 62 appended
Diagnostic left heart catheterization codes (93452, 93453, 93458-93461) and the supravalvular aortography code (93567) should not be used with TAVR or TAVI services (33361-33365, 0318T) to report:
Contrast injections, angiography, roadmapping, and/or fluoroscopic guidance for the TAVR or TAVI, aorta/left ventricular outflow tract measurement for the TAVR or TAVI, or post-TAVR or TAVI aortic or left ventricular angiography, is captured in the TAVR or TAVI services 33361-33365, and 0318T
Diagnostic coronary angiography performed at the time of TAVR or TAVI may be separately reportable if:
No prior catheter-based coronary angiography study is available and a full diagnostic study is performed, OR
A prior study is available, but as documented in the medical record:
The patient’s condition with respect to the clinical indication has changed since the prior study, OR
There is inadequate visualization of the anatomy and/or pathology, OR
There is a clinical change during the procedure that requires new evaluation
Other additional reporting instruction includes:
For same session/same day diagnostic coronary angiography services, report the appropriate diagnostic cardiac catheterization code(s) appended with modifier 59 indicating separate and distinct procedural service from TAVR/TAVI
Diagnostic coronary angiography performed at a separate session from an interventional procedure may be separately reportable
Other cardiac catheterization services are reported separately when performed for diagnostic purposes not intrinsic to TAVR/TAVI
Percutaneous coronary interventional procedures are reported separately, when performed
When transcatheter ventricular support is required in conjunction with TAVR or TAVI, the appropriate code should be reported with the appropriate ventricular assist device (VAD) procedure code (33990-33993, 33975, 33976, 33999) or balloon pump insertion code (33967, 33970, 33973)
Code 33410 is used to report the performance of cardiac valve replacement involving suturing at both the inlet and outlet portions of the valve
The stentless tissue valve lacks the rigid stent and sewing ring of valves described by code 33405
CODING TIP Codes 33533-33536 are used for reporting arterial grafting for coronary artery bypass
These codes include the use of the internal mammary artery, gastroepiploic artery, epigastric artery, radial artery, and arterial conduits procured from other sites
However, for harvesting the radial artery, code 35600 is used
Coronary Artery Bypass Procedures
Coronary artery bypass graft (CABG) procedures may be reported in three ways, depending on the type of operation performed
The first two reporting methods require only a single code as follows:
A bypass operation performed with only venous grafts
This is reported with a single code from the 33510-33516 series, reflecting the number of distal anastomoses performed
A bypass operation performed with only internal mammary arteries or other arteries
This is reported with a single code from the 33533-33536 series, with code selection again reflecting the number of distal anastomoses performed
The codes in this series are also used to report coronary artery bypass procedures with a combination of arterial and venous grafts
Bypass operations performed with a combination of venous and arterial grafts for distal anastomoses
The third reporting method requires the use of two codes:
A code from the 33517-33523 series to indicate that both arteries and veins were used
The appropriate code should describe the number of distal venous anastomoses used for the bypass
An arterial graft code from the 33533-33536 series to indicate the number of distal arterial anastomoses required for the bypass procedure
Codes in the combined arterial-venous grafting for coronary bypass series (33517-33523) are not to be reported alone
The appropriate vein graft code from this series is used in conjunction with a code from the arterial grafting series (33533-33536) to completely describe combined arterial-venous grafting for coronary bypass
As indicated by the symbol placed before each code, codes 33517-33523 are add-on codes and exempt from the use of modifier 51, Multiple procedures
Open Procurement of Graft Material
Open procurement of the saphenous vein graft is included in the description of work for codes 33510-33516 and 33517-33523 and should not be reported as a separate service or co-surgery
Arterial graft procurement is included in the description of work for codes 33533-33536 and should not be reported as a separate service or co-surgery
When a surgical assistant performs arterial and/or venous graft procurement, the assistant reports his or her services by appending modifier 80, Assistant surgeon, to the appropriate code from the 33510-33516, 33517-33523, or 33533-33536 series
Open procurement of these three types of graft material is reported separately as follows:
Upper extremity vein (+35500)
Femoropopliteal vein (+35572)
Upper extremity artery (+35600)
The procurement of these vessels for graft material requires additional decision making and more technically difficult surgical work
These procedures may be indicated for patients who, for example, have had previous bypass surgery or severe vascular disease, resulting in a lack of suitable superficial autogenous vessels for graft material
Codes 35500 and 35572 are designated as add-on codes and, as such, would not be reported alone
Code 35500 may be reported with CABG codes 33510-33536 and bypass graft codes 35556, 35566, 35571, and 35583-35587
code 35572 may be reported in conjunction with codes 33510-33516, 33517-33523, 33533-33536, 34502, 34520, 35001, 35002, 35011-35022, 35102, 35103, 35121-35152, 35231-35256, 35501-35587, and 35879-35907
Code 35600 is also an add-on code reported in conjunctin with codes 33533-33536
Modifier 51 should not be appended to codes 35500, 35572, or 35600
Endoscopic (Minimally Invasive) Venous Conduit Harvest
Harvesting of venous conduit by means of a minimally invasive endoscopic approach is not considered part of the CABG procedures (33510-33523) and is reported separately with the add-on code 33508
Endoscopic harvesting of venous conduit includes the use of a trocar to establish the approach and video assistance for intraoperative visualization of the venous and tissue structures
These integral procedural components are not separately reportable
Redo Operations
Code 33530 is an add-on code used to report coronary artery bypass or valve reoperation procedures performed more than one month after the original operation
Code 33530 is not reported alone
it is reported in addition to the appropriate code(s) to describe the bypass or valve procedure performed
Specifically, it is reported in conjunction with codes 33400-33496, 33510-33536, and 33863
Code 33530 is reported to reflect the increased difficulty associated with the redo procedure
Repeat sternotomy requires removal of previously placed wire sutures, which sometimes become embedded in the bony portion of the sternum
Because the anterior cardiac chambers, great vessels, and other mediastinal structures may be densely adherent to the posterior table of the sternum, the sternal incision must be made with extreme care to avoid potential hemorrhage
Once the mediastinum has been entered, the scarring and adhesions from previous surgery usually obscure the anatomic landmarks and make dissection both difficult and hazardous
When a redo coronary artery bypass procedure is reported, only the number and type of bypass grafts used in the redo procedure are reported
Nothing from the first operation gets reported for redos
The removal of embedded sternal wires is considered inclusive in the redo operation and should not be reported separately
Supportive procedures (eg, Swan-Ganz catheter insertion and removal, arterial line insertion and removal, placement and removal of pacemaker jwires, placement and removal of chest tubes) are also included in the coronary artery bypass operation codes and should not be reported separately
However, reoperation for bleeding, intra-aortic balloon insertion, and removal, as well as other services related to complications of the surgery, would be reported if they occurred
Cardiac Hybrid Procedures
A hybrid therapy or procedure is a mixture of therapies from different medical or surgical subspecialties
By definition, a hybrid cardiac procedure is a combination of surgical and catheter-based interventions to the heart combining the techniques of the interventional cardiologist with the cardiothoracic surgeon, electrophysiologists, echocardiographers, cardiac anesthesiologists, advanced-level nurse practitioners, physician assistants, cardiac catheterization lab nurses, operating room nurses, technicians, and perfusionists
The specialized hybrid cardiac operating suite is designed specifically for the cardiac surgical patient and can accommodate any cardiac surgical case, catheterization, or any collaborative hybrid procedure
Codes 33620 and 33621 are used to report techniques used to treat various forms of single ventricle and other complex cardiac anomalies
The Stage I hybrid approach procedures are performed primarily as sequential procedures in the neonatal population
Codes 33620 and 33621 should be reported together if both procedures are performed at the same session
Banding of the left and right branch pulmonary arteries is performed to balance the pulmonary and systemic blood flows in anticipation of eventual single ventricle palliation (33622)
Code 33690 refers to banding of the main pulmonary artery, not the branch pulmonary arteries, as is done in 33620
Code 33690 is used to reduce excessive pulmonary blood in infants with anomalies such as multiple ventricular septal defects or single ventricle and unrestricted pulmonary blood flow
(See Figures 4-38 and 4-39

)

FIGURE 4-38

Initial Hybrid Palliation, Stage I

FIGURE 4-39
Hybrid Palliation Stage II, Reconstruction
Ascending (Thoracic) Aortic Aneurysm Repair
The aortic root is the region of the aorta (the large artery distributing blood from the heart to the body) that is closest to the heart

The aortic root includes a tough fibrous ring (annulus), leaflets of the aortic valve, and the coronary ostia (the openings where the coronary arteries are attached)
In some patients an aneurysm can occur at the aortic root, causing the aorta to dilate or widen and the aortic valve to leak
Codes 33860, 33863, and 33864 are used to report several variations of repair and/or replacement techniques used for ascending (thoracic) aortic aneurysm repair
(See Figures 4-40 and 4-41

)

FIGURE 4-40

Aortic Root Remodeling: Coronary Arteries Reimplanted
CODING TIP Codes 33863 and 33864 include placement of chest tubes (32551) and placement of temporary pacing wires (33210, 33211)
Code 33863 also includes aortic valve replacement procedures (33405-33413)
Code 33863 is used to report a surgical technique also known as the Bentall operation wherein the entire aortic root and aortic valve are placed with a combination of a mechanical valve with an attached tube graft
Code 33864 represents valve-sparing aortic root replacement I in which the damaged section of the aorta is removed while preserving the aortic valve
FIGURE 4-41
Aortic Root Remodeling: Valve Spared
Cardiac Assist
Codes 33967 and 33968 are reported for percutaneous insertion (33967) and removal (33968) of an intra-aortic balloon assist device (IABAD) percutaneously through a femoral puncture in the groin
Insertion of the device, performed as an adjunct pumping assist measure, may be performed in addition to other cardiac procedures (eg, CABG) for maintenance of hemodynamic stability and should be reported with modifier 51 appended
When both percutaneous insertion of an IABAD and removal of the device are performed on the same day, it is appropriate to report these services with codes 33967 and 33968
And, if an IABAD is placed through the femoral artery using open technique and removed the same day, both 33970 and 33971 may be reported
One indication for this procedure is an acute myocardial infarction (MI)
Other indications could be the intent to do a left main coronary artery percutaneous coronary intervention
Most IABAD insertions for cardiogenic shock would not involve removal in the same setting
The insertion of a ventricular assist device (VAD) can be performed via percutaneous (33990, 33991) or transthoracic (33975, 33976, 33979) approach
The location of the ventricular assist device may be intracorporeal or extracorporeal
CODING TIP Code 36822 is reported for surgical insertion of cannula(s) for prolonged extracorporeal circulation for cardiopulmonary insufficiency (ECMO)
Open arterial exposure when necessary to facilitate percutaneous ventricular assist device (VAD) insertion (33990, 33991) may be reported separately (34812)
Extensive repair or replacement of an artery may be additionally reported (eg, 35226 or 35286)
VAD removal codes 33977, 33978, 33980, and 33992 include removal of the entire device, including the cannulas
Removal of a percutaneous ventricular assist device at the same session as insertion is not separately reportable
For removal of a percutaneous ventricular assist device at a separate and distinct session, but on the same day as insertion, report 33992 and append modifier 59 indicating a distinct procedural service has been performed
Repositioning of a percutaneous ventricular assist device at the same session as insertion is not separately reportable
Repositioning of percutaneous ventricular assist device not necessitating imaging guidance is not a reportable service
For repositioning of a percutaneous ventricular assist device necessitating imaging guidance at a separate and distinct session, but on the same day as insertion, report 33993 and append modifier 59
Replacement of the entire implantable ventricular assist device system, ie, pump(s) and cannulas, is reported using the appropriate insertion code 33975, 33976, or 33979
Removal (33977, 33978, 33980) of the ventricular assist device system being replaced is not separately reported
Replacement of a percutaneous ventricular assist device is reported using implantation code, 33990 or 33991
Removal (33992) is not reported separately
Endovascular Repair of Abdominal Aortic, Descending Thoracic Aortic, or Iliac Aneurysm
Placement of an endovascular graft for repair of an abdominal aortic aneurysm or for treatment of aneurysm, pseudoaneurysm, arteriovenous malformation, or trauma of the infrarenal abdominal aorta, descending thoracic aorta, or iliac artery is reported with component procedure codes 33880, 33881, 34800-34826, 34833, 34834, and 34900
Component coding systems require the use of multiple codes to fully describe the total procedure performed
There are specific codes to describe open femoral or iliac artery exposure, catheterization of the vessel, device manipulation and deployment, associated radiological S&I services, and closure of the arteriotomy sites
CODING TIP When the concepts of component coding are applied to endovascular repair of abdominal and thoracic aortic and iliac artery aneurysms, care should be taken not to confuse the use of the term component when reporting these procedures
Component coding refers to the use of multiple codes to describe various procedures performed
Unrelated to component coding, the prosthetic device placed to accomplish aneurysm treatment may have one or more components, or modules
Inclusive Procedures
Because a collapsed endoprosthesis is placed within the targeted treatment zone, balloon angioplasty and/or stent deployment within the target treatment zone, either before or after endograft deployment, is/are not separately reportable procedures
Introduction of guide wires and catheters should be reported separately (eg, 36140, 36200, 36245-36248)
Extensive repair or replacement of an artery should be separately reported (eg, 35226 or 35286)
Radiological Supervision and Interpretation
Fluoroscopic guidance for placement of the graft, as well as radiological supervision for angioplasty or stent deployment in the target zone, are included in the radiological S&I codes (75952-75954)
Therefore, fluoroscopic guidance is not separately reported
All X-ray imaging used for the procedure is included in the radiological S&I codes 75952-75954 (ie, fluoroscopic guidance, roadmapping, angiography, follow-up imaging to document completion
)
CODING TIP Add-on code 34806 should be used in conjunction with 33880, 33881, 33886, 34800-34805, 34825, 34900
Code 34806 should not be reported in addition to 93982 at the same session
Separate Interventional Procedures
Other interventional procedures performed at the time of endovascular abdominal aortic aneurysm repair should be additionally reported
Examples include renal transluminal angioplasty, arterial embolization, intravascular ultrasound, balloon angioplasty, and/or stenting of native arteries outside the endoprosthesis target zone, when performed before or after deployment of the graft
Transcatheter placement of an implantable wireless physiologic sensor may be performed during the endovascular repair
Add-on code 34806 describes transcatheter placement of the wireless physiologic sensor in the aneurysmal sac
Code 93982 describes subsequent analysis, interpretation, and report of the implanted wireless pressure sensor
It is not appropriate to report code 93982 with code 34806, because monitoring of the wireless pressure sensor occurs subsequent to hospital discharge at intervals based on guidelines set forth by the Food and Drug Administration (FDA) for endovascular repair and individualized by patient status
CODING TIP If the endovascular aortic or iliac repair procedure requires extensive repair or replacement of an artery, this should also be reported separately (eg, 35226, 35286)
Open (Direct) vs Endovascular Repair
While the graft material used in the repair may be similar to that used in an open repair, the method of attachment differs
In open (direct) repair of an abdominal aortic aneurysm (35081, 35102), the prosthesis is sutured proximally and distally to the artery undergoing repair
During endovascular repair, the device is anchored above and below the aneurysm, thus sealing off the aneurysmal sac
Balloon dilatation and/or stent placement may be necessary within the device to ensure proper seating and expansion of the device
The endovascular approach uses minimally invasive techniques as opposed to the surgical incisions required to perform the open (direct) repair
Endoprosthesis Devices
Codes 34800-34805 are used to report the placement of the primary prosthesis for endovascular repair of an infrarenal aortic aneurysm
The main difference between these codes is the device shape and number of components
FIGURE 4-42

Endovascular Repair of Abdominal Aortic Aneurysm: 34802

Using fluoroscopic guidance, a “compressed” prothesis is introduced through arteries in the groin and advanced into position with the aneurysm

Once in the aorta, the prothesis is expanded
Code 34800 describes placement of an endovascular tube graft, which can be placed through a single groin incision but frequently requires bilateral incisions for accurate placement
A closely related procedure to that described by code 34800 is 34805
Both are reported for endovascular aortic aneurysm repair (see Figure 4-42)
The primary differences are the length and shape of prosthesis required for effective aneurysm treatment
Code 34800 is used to report a tubular-shaped prosthesis that lies only within the abdominal aorta
Alternatively, code 34805 is used to report a procedure that requires the use of a longer prosthesis that extends into one iliac artery, therefore requiring a tapered cylindrical shape that is smaller in diameter at the distal end
All angioplasty performed within the target zone of the prosthesis deployment is included in 34805, and therefore is not separately reported, as are any stent placements within the body of the graft, completion arteriograms, and pressure measurements
Code 34802 is reported for placement of a modular (two-piece) bifurcated aortic endograft
Code 34802 differs from code 34805 in description of the configuration, length, and shape of the prosthesis required to treat the aneurysm effectively
Code 34802 is used to report a prosthesis that is constructed of two separate pieces that are joined inside the patient’s body during placement to make the ultimate configuration of an inverted Y
Code 34803 is reported for an endovascular abdominal aortic aneurysm repair using a modular bifurcated two-docking limb device
This code describes an inverted-Y-shaped 3-piece modular prosthesis, which spans the infrarenal abdominal aorta with the limbs extending into each iliac artery
The proximal ends of the limbs are joined to the main prosthesis component in a modular fashion after the main body component of the prosthesis is deployed within the aneurysm during the procedure
The distal ends of each limb are extended into the iliac arteries
Code 34804 is used to report use of a one-piece bifurcated (not modular) endoprosthesis
This procedure is similar to the one reported with code 34802, which has a Y configuration, but differs in that it is a one-piece construction
Code 34900 describes introduction, positioning, and deployment of an endovascular graft for treatment of aneurysm, pseudoaneurysm, or arteriovenous malformation, or trauma of the iliac artery
Code 34900 is used when only the iliac artery(s) is/are treated and the endograft is positioned solely in the iliac artery
Iliac artery aneurysms that are treated with an aorto-iliac device are coded with the appropriate endorepair code for that device, and 34900 is not additionally coded
Code 34808 is used to report the placement of an iliac artery occlusion device for prevention of retrograde blood flow into the aneurysm sac
Often this requires restoration of blood flow beyond the occlusion device by performance of a femoral-femoral bypass crossover graft, reported with CPT code 34813
Because open exposure of both femoral arteries is required to perform the femoral-femoral crossover, code 34812 should also be reported, appended by modifier 50, Bilateral procedure
Radiological S&I for aortic endograft repair is reported using code 75952, including all types of endograft devices reported using codes 34800-34805
For endovascular repair of an isolated iliac aneurysm treated with an iliac endograft, 75954 is used for the radiological S&I provided for the procedure
Open Surgical Exposure of Arteries
Open surgical exposure of the access arteries is often required to accommodate the large delivery sheaths used for placement of the endovascular prostheses and may be necessary when the arteries are diseased or of an inadequate diameter to allow passage of the large endovascular sheaths
Therefore, artery exposure (34812) and catheterization (36140, 36200, 36245-36248) for delivery of aortic endovascular prosthesis are separately reportable
Open femoral artery exposure by groin incision is reported with code 34812
Because this is a unilateral code, 50, Bilateral procedure, should be appended if surgical exposure is performed bilaterally
Surgical exposure of the iliac artery through a retroperitoneal or abdominal incision is reported with code 34820
Code 34833 is used to report the open surgical exposure of the iliac artery but also includes suturing of a temporary, large-diameter synthetic conduit onto the iliac artery
The endovascular repair is performed through this conduit, which is removed following completion of the procedure
Brachial artery exposure, reported using code 34834, may be performed when an alternate access is indicated (eg, during repair of a dissected aorta or for a patient with very tortuous iliac arteries)
Proximal or Distal Extension Prosthesis
When an infrarenal aortic or iliac endograft is not long enough or the intraprocedural angiogram indicates the presence of an endoleak at the time of the original endovascular repair, codes 34825 and 34826 are reported to describe the placement of an extension graft or cuff to complete the repair
Code 34825 is used to report placement of a proximal or distal extension prosthesis in the initial vessel
code 34826 is reported for each additional vessel
Reporting is based on the number of vessels requiring extension prosthesis placement, not the number of extensions or cuffs placed in a single vessel
Placement of an extension graft to extend the incomplete (short) limb of a modular graft (the “docking limb”) should not be reported separately
The radiological S&I for cuff placement is coded as 75953, used once for each vessel treated with cuffs or extensions
Endovascular extension placement performed during the postoperative period of the original procedure is reported with modifier 78, Unplanned return to the operating/ procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period, appended
Conversion to Open Surgical Procedure
In the event that complications arise during the endovascular repair procedure (eg, endoleak, dissection, occlusion of major arterial branches such as the renal arteries, acute occlusion of the aortic or iliac flow, device failure), codes 34830-34832 are reported to describe the conversion to an open surgical procedure for repair of complications involving a previously placed endoprosthesis
These procedures differ from direct (open) aneurysm repair procedures in that the direct aneurysm repair codes are used to report the initial open repair of a ruptured or nonruptured aortic aneurysm and do not include removal of the failed endograft or repair of damage associated with failed placement of an endograft
Bypass Graft and Composite Graft
Procurement of the upper extremity vein is not included when a CABG or lower extremity bypass procedure is reported
Code 35500 is separately reported in addition to the grafting procedure (codes 33510-33536, 35556, 35566, 35571, 35583-35587) for the harvest of a single vein segment for use in a lower extremity bypass or CABG procedure
Code 35600 is used to report the harvest of an upper extremity artery for use in CABG
This includes the procurement, implantation, and management of the free radial artery graft
Use of other arteries listed in the Coronary Artery Bypass Guidelines is included within the CABG procedure
Codes 35682-35683 are used to report the harvest of two or more vein segments from a limb other than that undergoing bypass for use as bypass graft conduit, reported with codes 35556, 35566, 35571, and 35583-35587, as appropriate
CODING TIP Lower extremity revascularization operations using synthetic conduits (ie, “other than vein”) are performed to provide a renewed inflow of blood to ischemic limbs
Examples of these procedures include aortobifemoral bypass (35646), aortofemoral bypass (35647), axillofemoral bypass (35621, 35654), iliofemoral bypass (35665), and femoral-femoral bypass grafts (35661)
Excision, Exploration, Repair, Revision
Codes 35879 and 35881 are used to report work performed on established lower extremity arterial bypass grafts to prevent thrombosis of the graft and possible subsequent limb loss
Codes 35879 and 35881 are used to report open revision of graft-threatening stenoses of lower extremity arterial bypass graft(s) (previously construction with autogenous vein conduit) using vein patch angioplasty or segmental vein interposition techniques
To differentiate, code 35876 is used for thrombectomy with revision of any noncoronary arterial or venous graft, including those of the lower extremity (other than hemodialysis graft or fistula)
Codes 35883 and 35884 are used to report the revision of the femoral anastomosis of a synthetic arterial bypass graft typically performed to treat an arterial narrowing (stenosis) at the site where a synthetic bypass graft has been sewn (anastomosed) to the native femoral artery (groin)
This type of stenosis may occur within a few months or many years after the original placement of the bypass graft
The open femoral artery synthetic bypass revision codes 35883 and 35884 are unilateral procedures differentiated by use of an autogenous or nonautogenous graft to repair the stenotic graft site
Modifier 50, Bilateral procedure, should be appended to report bilateral procedures
Codes 35883 and 35884 should not be reported for the same session
The reoperation procedures reported using 35700, 35875, and 35876 are not separately reportable as these procedures are inclusive of the procedures represented by codes 35883 and 35884
Code 35700 would not be separately reported, as codes 35883 and 35884 would always be performed in a reoperative field
Code 35500 would not be reportable if directly associated with code 35884, because the harvest of a short segment of vein from a distant site is included in the work of the open synthetic bypass revision using an autogenous graft
Vascular Injection Procedures
Code 36002 is used to report the treatment of iatrogenic pseudoaneurysms of the upper and lower extremities
Thrombin solution is introduced by needle injection into the pseudoaneurysm cavity until arterial bleeding has been demonstrably thrombosed
The work reported using code 36002 does not include imaging guidance, which is separately reportable if used
Dialysis Access
Codes 36147, 36148, and 75791 are used to report the diagnostic angiographic evaluation of an arteriovenous (AV) shunt
Code 36147 includes the work of establishing a single percutaneous access into the AV shunt with diagnostic contrast imaging of the dialysis circuit
However, if a fistulagram is performed without direct puncture and/or catheter placement into the hemodialysis shunt, that service would be reported with the radiology code 75791
In addition, code 75791 may also be used:
For a fistulagram through a catheter established in a fistula placed by another individual
When establishing access that is not a direct puncture of the shunt (eg, catheterization of an inflow artery)
When fistulagram is performed at surgery when films are submitted for radiological interpretation
When a second catheter access into the AV shunt is required, usually for therapeutic purposes, add-on code 36148 is used to capture the additional work associated with a subsequent puncture or catheterization
However, in the specific circumstance in which the second catheter access is performed after AV access imaging is performed through an already existing access, only 36147 should be reported
Codes 36147 and 75791 include all necessary imaging to evaluate the graft/fistula from the arterial anastomosis through the venous outflow, including the superior or inferior vena cava
Code 36147 also describes all needle/catheter manipulation within the access circuit to perform the diagnostic radiological study to evaluate the graft/ fistula
Additional reporting instruction includes:
Either 36147 or 75791 may be used to report arteriovenous shunt imaging
36147 is selected when a single percutaneous puncture is made to perform the contrast imaging
Code 75791 is selected when percutaneous access has already been separately established
Code 36148 should be reported in addition to 36147 if a second catheterization of the shunt is required for therapeutic purposes
It is not appropriate to report 75791 with either 36147 or 36148
FIGURE 4-43
Insertion of Tunneled Central Venous Catheter: 36657-36658
Insertion of Central Venous Access Device Procedures
To qualify as a central venous access catheter or device, the tip of the catheter or device must terminate in the subclavian, brachiocephalic (innominate), or iliac vein, the superior or inferior vena cava, or the right atrium
The venous access device may be either centrally inserted (jugular, subclavian, or femoral vein, or inferior vena cava catheter entry site) or peripherally inserted (eg, basilic or cephalic vein)
(See Figure 4-43
) The device may be accessed by using either an exposed catheter (external to the skin) or a subcutaneous port or subcutaneous pump
The procedures involving these types of devices fall into the following five categories:
Insertion (placement of catheter through a newly established venous access)
Repair (structural repair of broken device without replacement of either the catheter or the port or pump
This does not include pharmacologic or mechanical correction of intracatheter or pericatheter occlusion [see 36595 or 36596])
Partial replacement of only the catheter component associated with a port or pump device, but not entire device
Complete replacement of entire device via same venous access site (complete exchange)
Removal of entire device
There is no coding distinction on the basis of catheter size or between venous access achieved percutaneously (through the skin) vs by cutdown technique (open exposure of venous access site)
Device Insertion
Insertion (36555-36571) requires placement of the device through a newly established venous access site
(See Figure 4-44
) Insertion procedures are further distinguished according to patient age
With the exception of the tunneled, centrally-inserted, central-venous-access device with subcutaneous pump or port (36563-36566), separate codes are provided for patients younger than 5 years of age and those who are 5 years old or older
Repair of Device
When repair procedures (36575, 36576) are performed, the existing catheter and/or pump or port device(s) are restored to proper function without changing the existing catheter
For example, replacement of a broken hub on a dialysis catheter would be coded 36575
Repair of a device does not include either pharmacologic or mechanical correction of intracatheter or pericatheter occlusion
When performed, these procedures should be reported with code 36595 or 36596, as appropriate
FIGURE 4-44
Implantable Venous Access Port: 36570, 36571, 36576, 36578
Replacement
Complete (36580-36585) and partial (36578) replacement of a device are performed by using the existing venous access site
Complete device replacement involves the removal of the entire catheter and associated components and complete exchange using the same venous access site
Partial replacement involves exchange of only the catheter component of a port or pump device but not the port or pump device itself
This is performed by using the existing venous access site
The same code is used whether or not a new tunnel is created and whether or not a new subcutaneous pocket is created
The determination of replacement depends on use of the existing venous access
Removal
If an existing central venous access device is removed and a new one is placed by means of a separate venous access site, both the removal of the old device (36589, 36590) and insertion of the new device should be separately reported
The removal codes apply to catheters that are tunneled or have a subcutaneous port and involve typically sharp and/or blunt dissection to remove the catheter
Multicatheter Devices
The codes used for reporting repair and replacement (partial and complete) reflect procedures performed on single-catheter devices
If these procedures are performed for multicatheter devices, the appropriate code describing the service should be reported with a frequency of two
Replacement of the catheter portions only of a dual catheter subcutaneous pump involving two separate access sites should be reported by using code 36578 once for each separate catheter replaced
Insertion of a multicatheter device, requiring 2 catheters placed by means of two separate venous access sites, is reported with codes 36565 and 36566
Radiological Guidance
When imaging is used for these procedures, either for gaining access to the venous entry site or for manipulating the catheter into final central position, 76937 and/or 77001 are used, as appropriate, in addition to the code for the procedure(s) performed
Code 77001 includes contrast injection and venography if done from the same puncture as catheter placement
Venography may be coded separately only if the procedure requires venography for diagnostic purposes to allow placement of the central venous catheter and only if it must be done from a separate venipuncture site
Code 76937 should include documentation that the vessel was patent and that it was directly accessed under ultrasound guidance
A permanent image of the patent vessel should be recorded, but the code does not require imaging of the needle entering this vessel
Survey of multiple vessels to evaluate patency should only be reported with a single code, 76937
Arterial Code 36640 describes physician access for arterial catheterization that acts as a portal and remains in place until the completion of continuous prolonged chemotherapy infusion
Cutdown does not include arterial cannulization, use of a membrane oxygenator or perfusion pump, or the chemotherapy infusion
Infusion is additionally reported by codes 96420-96425, as appropriate
Extracorporeal Circulation Membrane Oxygenation Access Code 36822 is used to report the bedside adaptation of cardiopulmonary bypass similar to that used during open heart surgery, wherein blood pumped by the heart is diverted from the lungs so that the lungs have a chance to rest and heal
Code 36822 also is used to report the use of portable percutaneous cardiopulmonary support systems for the provision of rapid, temporary, complete support of cardiac and pulmonary function in critically ill patients who are unresponsive to conventional therapy
The machine removes the blood from the body to eliminate carbon dioxide, oxygenate the blood, and return it to the body for systemic circulation
Regional Chemotherapy Access Code 36823 is used to report placement of venoarterial cannulation for chemotherapy perfusion (supported by a membrane oxygenator or perfusion device) to an isolated region of an extremity to treat a neoplastic process and includes calculation and administration of the chemotherapy agent injected directly into the perfusate, thus not requiring additional reporting of the chemotherapy administration code(s) 96408-96425
Thrombectomy
The CPT nomenclature has several codes that describe various procedures for thrombectomy procedures in the management of arterial or venous grafts
Code 35875 is used to report an open procedure for thrombectomy of nonhemodialysis grafts or fistulae
Typically, this procedure is performed in arterial or venous bypass grafts that have been placed for relief of limb ischemia or repair of extremity aneurysm or arterial trauma
In contrast, codes 36831 and 36833 are reported for the performance of open thrombectomy of autogenous or nonautogenous dialysis grafts, in which a balloon catheter or other device is passed in both the proximal and distal directions to remove the thrombus
Code 36833 is further distinguished by the concurrent performance of an arteriovenous (A-V) access revision in addition to the thrombectomy procedure
Code 36832 is reported when an A-V access revision only is performed without thrombectomy at the operative session
Code 36870 is reported for the procedure in which the approach for the autogenous or nonautogenous graft thrombectomy is performed percutaneously
The removal of the thrombus, as reported by this code, can be performed by any technology, including mechanical and/or pharmacologic thrombolysis in any combination of techniques or devices
Administration of a pharmacologic thrombolytic agent, when performed by any technique, is an inherent component of this procedure
Procedures performed in addition to the thrombectomy (eg, access into graft or fistula, angioplasty, imaging, stenting) are reported separately
Codes 36860 and 36861 are used to report thrombectomy procedures performed on external types of dialysis devices
External dialysis devices are devices that contain dual-lumen central lines that have external ports
These types of catheters do not require open incisional techniques to remove the clots
This revision differentiates these procedures from thrombectomy procedures that require open procedures to perform (ie, procedures that require opening the vessel to remove the thrombus, coded as 36831)
Hemodialysis Access Creation Code 36818 is reported for the performance of an open upper arm cephalic vein transposition to include tunneling for brachiocephalic anastomosis
This procedure requires 2 upper-arm incisions, one medial over the brachial artery, the other lateral to expose the vein
A tunnel is created between the incisions, and complete dissection of a substantial portion of the cephalic vein is required to allow it to be moved to a more superficial location and pulled through the tunnel for anastomosis with the brachial artery on the medial aspect of the upper arm
This approach is often performed in patients with large or obese arms
Code 36819 is reported for direct A-V anastomosis by basilic vein transposition
The result of this procedure is the creation of permanent hemodialysis access
This extensive procedure includes the dissection of the basilic vein from the antecubital crease to the axilla
It also includes the associated nerve preservation, tunnel creation, vein relocation, and anastomosis
Code 36818 differs from code 36819 in that the procedure described by code 36819 consists of the basilic vein transposition for brachiobasilic anastomosis
Additionally, code 36820 consists of forearm vein transposition performed in the lower arm between the elbow and the wrist
(See Figure 4-45

)

FIGURE 4-45

Arteriovenous Anastomosis, Open
by Forearm Vein Transposition
Autogenous conduit such as a piece of the patient’s greater saphenous vein (36825) or a synthetic vein (36830) is used to connect an artery and vein
Code 36821 is used to report a less extensive procedure that includes direct anastomosis of a vein to an artery
This procedure is typically performed at the wrist and involves only a moderate amount of arterial and venous dissection
Code 36830 is used to report the most commonly performed hemodialysis access operation—the placement of a synthetic subcutaneous tube graft in which one end is anastomosed to an artery such as the brachial artery and the other to a large vein
(See Figure 4-46
) This is most often performed when patients do not have large, visible wrist veins for the performance of a native (eg, Cimino) fistula reported with code 36821
FIGURE 4-46
Arteriovenous Fistula: 36825-36830
Transcatheter Procedures
Transcatheter procedures involve placement of a catheter into the arterial or venous system to perform selective or superselective diagnostic or therapeutic intervention(s) in the vessel(s) per se, or for the purpose of treating organic disease (eg, uterine fibroid tumors, hepatic tumors)
Mechanical Thrombectomy
The introductory language within the CPT code set has three sections under the mechanical thrombectomy subheading:
Guidelines applicable to all mechanical thrombectomy codes
Guidelines specific to arterial mechanical thrombectomy codes
Guidelines specific to venous mechanical thrombectomy codes
The guidelines applicable to this entire family of codes clearly state that other interventions are separately reportable
The arterial mechanical thrombectomy codes 37184-37186 are reported per vessel, while the venous mechanical thrombectomy codes 37187 and 37188 are reported per session
Both codes 37187 and 37188 are reported once
The only instance in which it would be appropriate for code 37187 to be reported twice in one session is if the procedure is done bilaterally through two separate access sites
In that case, the guidelines for this group of codes states to use modifier 50
In the event the procedure is performed on one day and repeated treatment occurred on a subsequent day of the same thrombolytic therapy, it would be reported with one code—37187 for the first day of treatment and 37188 if done on a subsequent day of treatment
For arterial mechanical thrombectomy, the rules are slightly different
The primary arterial mechanical thrombectomy code (37184) is reported per vessel
The add-on code for additional vessels within the same vascular family (37185) includes all additional vessels treated within the same vascular family (ie, 37185 is used once if one additional vessel is treated, and also is used only once if multiple additional vessels are treated
)
CODING TIP The diagnostic imaging typically performed in advance of a scheduled percutaneous radiofrequency ablation procedure to identify the presence of liver tumors is reported separately
Other Procedures
Code 37204 describes performance of therapeutic occlusion of nonhead, nonneck, and non-central nervous system (CNS) arteries or veins (for head or neck and CNS embolization, see 61624 and 61626)
The embolization material is delivered through small catheters to temporarily or permanently stop flow to the area supplied by a blood vessel
Common indications for embolization include the presence of abnormal arteries or veins or a combination of both (arteriovenous malformations)
life-threatening bleeding in the lungs, gastrointestinal tract, or pelvis
and tumors that are supplied by a large number of blood vessels
Some transcatheter embolization agents used when reporting 37204 include gelatin sponge, polyvinyl alcohol, coils, and ethanol and glue
Embolization procedures are reported with component coding
The selective catheterization code for the desired vessel(s), angiography (injecting contrast), if not previously performed, S&I embolization code (75894), and surgical embolization code (37204) are reported for a transcatheter embolization procedure
Both of the embolization codes (37204 and 75894) are reported one time each for embolotherapy performed in a single operative field, regardless of the number of vessels or numbers of embolization agents required to complete the embolization
However, the embolization codes 37204 (surgical component) and 75894 (S&I component) are reported for each operative field treated (eg, right and left kidney, right and left lung)
In this case, modifier 59, Distinct procedural service, should be appended to designate the separate sites treated
In addition to the embolization codes, codes for diagnostic angiogram or venogram are reported if the diagnostic study is done at the time of the embolization
Code 75898, Angiogram through an existing catheter, is also used once for each field treated for the angiogram done to document completion of the embolization
CODING TIP The uterine artery embolization procedure for postpartum hemorrhage is reported with the embolization codes, selective catheter placement, radiological S&I (imaging) and postembolization angiogram (37204, 75894)
This study is coded differently than elective uterine artery embolization performed for treatment of fibroid tumors, which is reported with code 37210 and includes vascular access, vessel selection(s), all angiography performed, roadmapping, radiological S&I, and postembolization angiograms
Code 37210 is used to report the complete procedure to treat uterine fibroids with bilateral uterine artery embolization
This procedure is an exception to the previously listed rules for coding therapeutic embolization
Codes 37215 and 37216 are reported for percutaneous stent placement in the cervical portion of the extracranial carotid artery
The codes are further distinguished by whether or not an embolic protection system was used
Unlike procedure code 37204, codes 37215 and 37216 are inclusive of all aspects of the therapeutic procedure, including catheterization, diagnostic angiography of the ipsilateral carotid, and all related radiological S&I
It is important to note that the appropriate codes for reporting carotid catheterization and imaging of the ipsilateral carotid only are reported for those circumstances in which the carotid catheterization and imaging have been performed and stent placement is not indicated for treatment
Additionally, all arteriographic imaging of the ipsilateral cervical and cerebral carotid arteries is included and not separately reported
Therefore, codes 37215 and 37216 include the following:
Selective ipsilateral carotid catheterization
All diagnostic imaging for ipsilateral carotid, from its origin through the cerebral vessels
All related radiological S&I required to complete the therapeutic stent placement
Placement of the stent and all ballooning of the vessel
Placement and retrieval of the embolic protection device (37215 only)
When the initial ipsilateral carotid arteriogram (including imaging and catheterization) confirms the need for carotid stenting, codes 37215 and 37216 are inclusive of these services
If carotid stenting is not indicated, then the appropriate codes for carotid catheterization and imaging would be reported in lieu of codes 37215 and 37216
Endovascular Lower Extremity Revascularization
Codes 37220-37235 are used to describe lower extremity endovascular revascularization services performed for occlusive disease
This family of codes is built on progressive hierarchies with the codes for more intensive services inclusive of lesser intensive services, namely:
The work of accessing and selectively catheterizing the vessel and traversing the lesion
Radiological supervision and interpretation (S&I) directly related to the intervention(s) performed
Embolic protection, if used
Closure of the arteriotomy by pressure and application of an arterial closure device or standard closure of the puncture by suture
Imaging performed to document completion of the intervention in addition to the insertion(s) performed
Balloon angioplasty (eg, low-profile, cutting balloon, cryoplasty)FIGURE 4-47

Iliac and Lower Extremity Arterial Anatomy Territory 37220-37235
Codes 36140, 36200, 36245, 36246, 36247, 36248, 76000, 75960, 75962, and 75964 should not be reported in addition to codes 37220-37235 within the treated lower extremity artery vascular family, because these procedures are considered inherent in each code
However, there are instances in which catheterization of specific artery(ies) (eg, external iliac, common iliac) may or may not allow for additional reporting, in particular 36245 or 36246
Selective catheterization of the renal, celiac, and superior mesenteric arteries in the same setting remains separately reportable
(See Figure 4-47
)
CODING TIP Closure of venotomy and arteriotomy sites is not separately reportable and considered inherent in the completion of coronary and lower extremity arterial endovascular interventional catheterization procedures
An exception is for facility reporting under the Outpatient Prospective Payment System (OPPS) in the outpatient hospital setting, the Centers for Medicare and Medicaid Services (CMS) has requested use of HCPCS Level II code G0269, Placement of occlusive device into either a venous or arterial access site, post-surgical or interventional procedure (eg, angioseal plug, vascular plug), for tracking purposes
Each lower extremity revascularization code (37220-37235) includes the associated catheterization of the treated vessel
Exceptions to this reporting instruction are illustrated in the following two interventions but do not suggest nor imply these are the only instances in which additional reporting may be appropriate
EXCEPTION #1
A diagnostic study is performed from a separate puncture site than what was used for the interventional procedure
The appropriate catheterization code for the diagnostic study would be reported with modifier 59 to indicate that this catheterization is separate from that used for the intervention
Example: A diagnostic aortogram with bilateral lower extremity arteriogram is performed from a right femoral puncture with the catheter advanced into the abdominal aorta for imaging
A proximal left common iliac stenosis is identified and treated via a second puncture of the left common femoral artery
In this case, the right groin approach via the aortic catheterization would be reported with code 36200 with modifier 59 appended
The left femoral puncture with catheter placement for the iliac intervention is included in the therapeutic code and is not separately reported
EXCEPTION #2
An intervention is performed in a non-lower extremity artery at the same setting as a lower extremity endovascular intervention
Many interventions other than those in the lower extremity continue to follow component coding guidelines, so the catheterization for the additional intervention(s) would be coded in addition to the lower extremity intervention code and reported with modifier 59 appended to signify that this catheterization was not part of the lower extremity revascularization intervention
Example: A right common iliac stenosis is treated with stenting via a right femoral approach
At the same time, the right renal artery origin is also treated with stent placement
In this case, the right iliac treatment is reported with 37221, which includes the work of placing a catheter into the aorta
However, additional selective work is required to treat the renal artery, and this is reported with 36245 with modifier 59 appended (when a first order selection is used for the renal stenting)
Category III Peripheral Atherectomy Codes (0234T-0238T)
The supra-inguinal atherectomy codes 0234T-0238T are structured differently than atherectomy performed below the inguinal ligaments (37225, 37227, 37229, 37231, 37233, and 3735)
The inclusive services are outlined as follows:
Supra-inguinal arterial atherectomy procedures performed percutaneously and/or through an open surgical exposure
Surgical work of performing the atherectomy
Radiological supervision and interpretation of the atherectomy
CODING TIP Codes 0234T-0238T are used to report atherectomy performed by any method (eg, directional, rotational, laser) in arteries above the inguinal ligaments
These codes are structured differently than the codes describing atherectomy performed below the inguinal ligaments (37225, 37227, 37229, 37231, 37233, 37235)
Unlike the atherectomy codes for infra-inguinal arteries, 0234T-0238T do not include:
Accessing and selectively catheterizing the vessel and traversing the lesion
Embolic protection, if used
Other intervention(s) used to treat the same or other vessels
Closure of the arteriotomy by any method
Therefore, consistent with the “component coding” convention for reporting interventional intravascular procedures, the appropriate selective catheterization code should also be reported
PRINCIPLES OF CPT CODING
BOOK III COMPLETED

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