CardiovascularCardiovascular Diagnostic and Diagnostic and

Procedural CodingProcedural Coding

Irene Mueller, EdD, RHIAIrene Mueller, EdD, RHIA

June 9, 2010June 9, 2010

10am – Noon MDT10am – Noon MDT

MHAMHA

20102010

Objectives – First hourObjectives – First hour

• Heart Dx coding

• Vessel Dx coding

Objectives - 2Objectives - 2ndnd hour hour

• Heart Procedures– Diagnostic– Therapeutic

• Vessel Procedures– Diagnostic– Therapeutic

• Cardiac Rehabilitation

• Resources http://anatomy.med.umich.edu/radiology/xray/images/femoral_artery_occlusion.gif

Cardiac Diagnostic CodingCardiac Diagnostic Coding

• VSD 745.4• PDA 747.0• Coarctation of the Aorta

– 747.10• ASD – 745.5 – 745.8• Tetralogy of Fallot• 745.2• Transposition of Great

Arteries• 745.10 – 745.19

• CAD• MI• HTN• Heart failure• Arrhythmias

Congenital Congenital Dx Coding Dx Coding

• If no specific term in ICD, use more general terms in the AI, such as – Anomaly, Defect, Deformity, etc.

• If anomaly is specified, but no code, use code for other specified anomaly of that type/site OR unspecified anomaly of that general type/site

• Add’l codes for manifestations assigned when specific codes not available

Congenital Congenital Dx Coding Dx Coding

• Codes from Chapter 14 can be reported for a patient of ANY age

CADCAD

• AKA - ASHD, coronary ischemia, and coronary ateriosclerosis (atherosclerosis)

• Code 411.1 (unstable angina, crescendo angina, preinfarction angina, and impending MI) as PDX ONLY when NO underlying condition determined and NO surgical intervention

• IF a CABG or PTCA is performed, 414.0x is coded with additional code for unstable angina

CAD codingCAD coding

• IF patient does NOT have hx of CABG, assign code 414.01

• IF patient does have a history of CABG, then assign appropriate code from 414.00, 414.02-414.05 range– BUT must query Dr for specific artery

• 414.06 and 414.07 are used for CAD of a transplanted heart

Acute MI - 410Acute MI - 410• Two factors must be known:

– Site or type of AMI (4th digit)• transmural, subendocardial• check EKG interpretation for specific info

– Episode of care (5th digit)• Initial, Subsequent, Unspec

• The 4th digit of 9 (unspecified site) & 5th digit of 0 (unspec. episode of care)– NEVER used for inpatient encounters– Query physician for clarification– These can be used in outpatient settings

Acute MI – Episode of CareAcute MI – Episode of Care

• 5th digit used to indicate – initial or – subsequent episodes of care in the 8 weeks

after the MI – It is safe to assume a MI admission is initial IF

the hx does not mention previous MI

Chronic/Healed MIChronic/Healed MI

• Chronic MI or w/duration 8+ weeks - 414.8

• MI documented as old/healed - the coder must determine if this is still being tx or affecting care

• 412 is NOT assigned when current CAD is present

• 412 is only assigned if it has an impact on the current care

MI ExampleMI Example

• Pt admitted to Hospital A on 3/3 with severe chest pain, dx as an anterolateral wall AMI (no hx of earlier care) 410.01

• Pt was transferred to University hospital later on 3/3 for angioplasty 410.01

• Retransferred to Community Hospital on 3/6 to continue recovery. Pt discharged on 3/8. 410.01

• Same pt readmitted to Community Hospital on 3/12 because he was having severe chest pains. Extension of the infarction was suspected but R/O 410.02

CAD/AMI SequencingCAD/AMI Sequencing• Patient adm. for angina due to CAD

– CAD is sequenced 1st w/ add’l code for angina

• Patient adm. w/unstable angina and CAD and AMI after admission,– AMI is sequenced 1st w/ CAD as an additional code– Unstable angina not assigned, since progressed to AMI

• Patient adm. w/AMI and CAD; AMI code 1st w/ code for CAD

• Pt adm. w/impending MI and CH, AMI after admission– AMI is sequenced 1st w/ appropriate codes for the CHF

• Note: NO 411 assigned w/code from 410 UNLESS documented postmyocardial infarction syndrome, postinfarction angina, or Dressler's syndrome

Heart FailureHeart Failure

• Diastolic vs Systolic

• Knowing systolic vs diastolic dysfunction is essential– long-term treatments are different– MS-DRG impact

Systolic heart failure (428.2x)Systolic heart failure (428.2x)

• More common– dilation of left ventricle– with impaired contraction of heart muscle– decreased outflow of blood from the heart

• Heart contracts w/less force– Can’t pump our as much blood as normal– More blood remains in lower chambers and

accumulates in veins

• CAD is a common cause

Diastolic heart failure (428.3x)Diastolic heart failure (428.3x)

• Normal left ventricle with impaired ability to relax muscles between contractions – heart is stiff and doesn’t relax normally– results in the inability to receive, as well as

eject, blood. – As in systolic dysfunction, the blood returning

to the heart then accumulates in the veins

• Often, both forms occur together (428.4x)

55thth digits for 428.2-428.4 digits for 428.2-428.4

• 0 unspecified

• 1 acute

• 2 chronic

• 3 acute on chronic

• Acute on chronic = patient w/chronic heart failure now has superimposed acute flare-up.

• Assign 5th digit based on documentation

HEART FAILUREHEART FAILURE

• All codes for heart failure include– Dyspnea, orthopnea,

bronchospasm, acute pulmonary edema

• Right Heart Failure – usually follows left-sided heart failure; is congestive heart failure (includes left-sided heart failure)– 428.0

Compensated (near-normal) Compensated (near-normal) and Decompensated Heart and Decompensated Heart

Failure Failure • Heart muscle compensation mechanisms

include– cardiac hypertrophy– raised arterial pressure– ventricular dilation – increased contraction force

• Code assignment is NOT affected by these terms

CardiomyopathyCardiomyopathy

• Dilated heart, flabby heart muscles, normal coronary arteries

• Types include– Alcohol 425.5– Congestive, constrictive, hypertrophic, obstructive

425.4• In most cases tx focuses on mgt of CHF and in those

instances the heart failure, 428.0 or 428.1, is the principal diagnosis, with cardiomyopathy, 425.4, assigned as add’l dx

• Dual coding is required for cardiomyopathy due to other conditions, such as amyloidosis or HTN

Heart Failure ExamplesHeart Failure Examples

• Left heart failure with B9 HTN 428.1, 401.1

• Acute CHF due to HTN 402.91, 428.0

• CHF due to hypertensive heard disease– 402.91, 428.0

• Acute pulmonary edema with L ventricular failure 428.1

427.5 Cardiac Arrest427.5 Cardiac Arrest• This code is PDx ONLY when the underlying

cause CANNOT be determined– ex: pt is in cardiac arrest when arriving at hospital

and cannot be resuscitated

• Can be add’l dx when cardiac arrest occurs during admission and the pt is resuscitated or resuscitation is attempted

• 997.1 - Cardiac arrest as a complication of surgery

• DO NOT use these codes to indicate pt death

HTN code categoriesHTN code categories

• ICD-9-CM has 5 HTN categories to identify type – 401 Essential hypertension – 402 Hypertensive heart disease – 403 Hypertensive renal disease – 404 Hypertensive heart and renal disease – 405 Secondary hypertension

• 401-404 show progression of disease progress from vascular origin to end organs involved

HTNHTN• ICD-9-CM classifies HTN

– by type (primary/secondary) and– nature (B9, malignant, unspecified)

• Hypertension described as controlled or history of HTN usually refers to an existing HTN, if it is still under tx, then code the HTN

• due to HTN (direct causal relationship) or hypertensive (implied relationship) indicate that the HTN has caused other problems – Many combination codes

B9 or Unspecified HTNB9 or Unspecified HTN

• Unspecified or Hypertension, NOS is coded to 401.9

• The coder should NEVER assume that hypertension is malignant or benign without physician documentation

• • "Benign" must be stated by the physician along

with hypertension to code 401.1

HTN TableHTN Table

• In AI, under main term – Hypertension

• Subterms listed in 1st column– use same AI conventions

• With, due to, hypertensive, etc.

• 2nd – 4th columns– Malignant, B9, and unspecified– Dr must document for coder to use Mal/B9

• Codes MUST be verified in TL

Hypertensive Hypertensive Disease Disease

• Includes cardiomegaly, cardiovascular disease, myocarditis, degeneration of the myocardium, and heart failure

• When the dx statement mentions both HTN AND heart condition, but does NOT indicate a causal relationship, separate codes are assigned

• 402 is a combination code for hypertensive heart diseases (5th digit indicates presence of heart failure), add’l code needed to specify type of heart failure

HTN and Renal DiseaseHTN and Renal Disease

• Dx statement has HTN AND renal disease– ICD usually ASSUMES a cause/effect

relationship (403)– 5th digit indicates presence of renal failure – 403 does NOT include ACUTE renal failure

• 5th digits • 0 - with CKD stage I - stage IV, or unspecified • 1 - with CKD stage V or end stage renal disease • Appropriate 585 code is add’l code to id stage of

kidney disease

Hypertensive Hypertensive Heart Heart ANDAND Renal Disease Renal Disease

• 402 condition AND 403 condition exist– 404 combination code is assigned– 5th digit indicates if CHF, renal failure, or both

are present

404 5404 5thth digits digits• 0 – w/o heart failure & with chronic kidney disease

(CKD) stage I - stage IV, or unspec.

• 1 – w/heart failure, with CKD stage I - stage IV, or unspecified

• 2 - w/o heart failure, with CKD stage V or ESRD (ESKD)

• 3 - w/heart failure and with CKD stage V or ESRD

• Appropriate 585 code is add’l code to id stage of kidney disease

HTN, DM, and CKDHTN, DM, and CKD

• When dx indicates that both HTN AND DM are cause of CKD, use two codes– appropriate code from 403 OR 404 and – 250.4x

– Add’l code for the stage of CKD

HTN w/other conditionsHTN w/other conditions

• Although HTN may occur with other conditions and accelerate their development, ICD does not have combination codes for these– Need multiple coding

EBP vs HTNEBP vs HTN• 796.2 - Elevated blood pressure w/o

specificity, NOT code from 401– Must be documented by Dr, not just recorded

• Blood pressure readings vary, tend to increase with age (white coat HTN)

• HTN dx must be based on a SERIES of readings

HTN Coding ExamplesHTN Coding Examples

• CHF due to HTN 402.91, 428.0

• CHF with HTN 428.0, 401.9

• HTN, chronic kidney disease 403.91

ArrhythmiasArrhythmias

• Main Terms– Arrhythmia– Block– Dysrhyrhmia– Specific terms (Bigeminy, etc)

• 426. - Conduction Disorders

• 427. – Cardiac Dysrhythmias

Vessel Dx CodingVessel Dx Coding

• AV Malformations

• Arteriosclerosis

• Emboli

• Phlebitis

AV MalformationAV Malformation

• Malformation (congenital) – see also Anomaly

• Anomaly– Arteriovenous

• sites

Arterio/Athero-sclerosis Arterio/Athero-sclerosis of Extremitiesof Extremities

• Coder needs to determine – 1) if native arteries or graft involved, – 2) if progression of disease includes

• A) claudication• B) rest pain• C) ulceration, or• 4) gangrene

• Usually affects legs, but can be in arms

Progression of arteriosclerosis Progression of arteriosclerosis (PAD) (PVD)(PAD) (PVD)

• Intermittent claudication (from Latin for “limping”)

• A) pain when walking– As worsens, length of walk

before pain gets shorter, rest stops pain

• B) rest pain– Sitting down, resting no

longer gets pain to stop

• C) ulceration, or• 4) gangrene

• When coding, each stage includes the previous one

• Ex: “claudication with ulcers”– Code only 440.23

Thrombosis and ThrombophlebitisThrombosis and Thrombophlebitisof Extremities of Extremities

• Thrombosis = clot has formed Thrombophlebitis = clot is inflamed (swelling, redness, pain)

• Atheroembolism = cholesterol crystals from atheromatous plaques from vessels such as the aorta or renal artery

EmboliEmboli

• Embolism = Main Term– Type (OB, air, fat, etc.)– Location (body part)– Cause (due to, following, postop)

VTE (2010 Code Changes)VTE (2010 Code Changes)

• Venous Thrombosis and Embolism– Occurs in extremities, thorax, neck

• Acute = New, initial anticoagulation tx• Chronic = Old, continuation of est. tx• Deep= DVT• Superficial• Physician documentation of venous

thrombosis is coded as acute if not further specified

VTEVTE• 453.40-42

(Rev)“Acute”– Deep, Lower

extremities

• 453.50-52 (New)– Chronic, Lower

Extremities

• 453.6 (New)– Superficial, Lower ext.

• 453.71-79 (New)– Chronic, Upper

• 453.81-89 (New) – Acute, Upper Extremities– Antecubital, basilic, cephalic,

brachial, radial, ulnar, axillary, subclavian, internal jugular, etc.

• NOT same as V12.51 personal hx of

• V58.61– Long-term (current) use of anti-

coagulants– Add’l code, if applicable with

these codes

416.2 Chronic Pulmonary Embolism416.2 Chronic Pulmonary Embolism

• Small blood clots travel to the lungs repeatedly over a period of years

• Symptoms build up gradually, including• SOB• leg swelling, and • general weakness

• V58.61 is used with this code if applicable

Coding ExamplesCoding Examples

• Thrombophlebitis, femoral vein, L leg 451.11

• Arteriosclerotic ulcer and gangrene of lower leg 440.24

Break TimeBreak Time

Diagnostic Diagnostic Procedures Procedures

• EKG (ECG), Holter monitor• Stress test (Treadmill)• Thallium or cardiolite scan• CT scan• Echocardiography• Stress echocardiogram• Angiograms• ACC/AHA Guidelines for Stable Angina

EKG (ECG)EKG (ECG)• ICD – 89.52

• CPT – • 93000 -- Electrocardiogram, routine ECG with

at least 12 leads; with interpretation and report• 93005 -- ... tracing only, without interpretation

and report• 93010 -- ... interpretation and report only.

HolterHolter

• Invented by Dr. Norman Holter– Worn from 1 – 3 days– During normal activities

• http://www.actionecho.com/videos/holter-monitor

• 89.50• 93224-93233 (wearable ecg rhythm derived

monitoring)

Stress TestsStress Tests

• Exercise (Treadmill)– Affect on ST segment on EKG

• Pharmaceutical– Basal Dilators– Perfusion defect

• Thallium scan after exercise

• 89.41-89.44

Stress Test Coding - CPTStress Test Coding - CPT

• Stress tests have three components:– 93017 Technical (tracing only)– 93018 Interpretation and report (Dr. service)– 93016 Supervision (physician service)

• 93015 = global service– includes all services above– used when the same entity provides all parts

of the service

CT ScanCT Scan

• A series of detailed pictures of areas inside the body taken from different angles

• Created by a computer linked to an x-ray machine

• AKA - CAT scan, computed tomography scan, computerized axial tomography scan, and computerized tomography

• http://www.youtube.com/watch?v=ROQlHtjSuaU

CPT coding for CT ScanCPT coding for CT Scan

• Medicare Reimbursement for Cardiac Computed Tomography and Computed Tomographic Angiography. GE Healthcare. January 2009.– http://www.gehealthcare.com/usen/community

/reimbursement/docs/CT_CTA10_2009.pdf

EchocardiographyEchocardiography

• Transthoracic (TTE)– 88.72,

– 93306

– 93307

– 93308

• http://www.bing.com/videos/watch/video/echocardiogram/1f9ec507a1d6ecc805271f9ec507a1d6ecc80527-63654921571

• Transesophageal (TEE)– 88.72, 89.68

– 99312-99318

• http://www.actionecho.com/videos/transesophageal-echo

Stress echoStress echo

• Dobutamine Stress Echocardiogram (dobutamine echo, pharmacological echocardiogram)– Makes your heart “think” it is exercising

• Exercise stress echo test involves exercising on a treadmill or stationary cycle while being monitored

• http://actionecho.com/videos/stress-echo

Coding Stress EchosCoding Stress Echos

• Outpt and Inpt

• New Echocardiography Codes and Descriptions for 2009. American Society of Echocardiography Coding and Reimbursement Newsletter , January 2009.– http://www.asecho.org/files/public/Codingnew

sJan09.pdf

Therapeutic Therapeutic Procedures Procedures

• Revascularization - Percutaneous Intervention (PCI)– Angioplasty w/wo

stenting (PTCA)• single vessel, focal

lesion, location

– CABG • three vessel

• Stable Angina

• Arrhythmias– Cardioversion – 99.61,

99.62

– Ablation -37.34

– Pacemaker – some outpt, some inpt 00.5x, 37.6-8

– Implantable cardioverter defibrillator

• Cardiac resynchronization device – 00.5x

– Noninvasive programmed electrical stimulation [NIPS] - 37.20

PTCAPTCA• Coronary angioplasty - dilation of a blocked artery with

a balloon • 00.66 – PTCA • 00.40-00.43 – identifies the number of vessels treated • 00.44 –vessel bifurcation, if performed (only report

one time regardless of # vessel bifurcations treated) • 36.04 –infusion of platelet inhibitor or other

intracoronary artery thrombolytic agent, if performed • 99.10 –infusion of thrombolytic agent such as tissue

plasminogen activator (TPA, if performed)

Coronary StentingCoronary Stenting• May also be performed with PTCA • Once vessel dilated using balloon, physician

inserts a stent to prevent re-closure

• 36.06 or 36.07 – insertion of stent • 36.06 is reported for non-drug-eluting stents• 36.07 is reported for drug-eluting stents

• Note: drug coated (i.e., heparin coated) stents are reported with code 36.06

• 00.45-00.48 – number of stents

CABGCABG• 36.11-36.14 – identify the number of aortocoronary

bypass grafts• AND/OR 36.15-36.16 – identify the number of internal

mammary-coronary artery bypass grafts• AND/OR · 36.17 – use when an abdominal-coronary

artery bypass is performed (i.e., gastric artery) • AND/OR · 36.19 – use when coronary artery bypass is

performed with vessels other than coronary, internal mammary, or abdominal. AND (if performed)

• 39.61 – extracorporeal circulation (i.e., cardiopulmonary bypass)

• 00.16 – pressurized treatment of venous bypass graft with pharmaceutical substance

Stable AnginaStable Angina

• A – aspirin and anti-anginals

• B – Beta-blockers and > 130/90 BP

• C – low Cholesterol and no Cigarettes

• D – Diet (low lipid) and Diabetes

• E – Exercise and Education

• ACC/AHA Guidelines (2003)

Arrhythmia TxArrhythmia Tx

• Arrhythmias– Cardioversion – 99.61, 99.62 – Ablation -37.34– Pacemaker – some outpt, some inpt 00.5x,

37.6-8– Implantable cardioverter defibrillator

• Cardiac resynchronization device – 00.5x– Noninvasive programmed electrical stimulation [NIPS]

- 37.20

CardioversionCardioversion

• Can be done using– energy shock (electric cardioversion)

• Device placed internally or externally • External – emergency – defibrillator 92960• Internal – chronic – implanted defibrillator 92961

– medications (pharmacologic cardioversion)• Oral or IV• Inpt or Outpt

• used to slow or terminate tachycardia

Cardiac massageCardiac massage

• Intermittent compression of the heart – Pressure applied over the sternum (closed cardiac

m.) – Directly to the heart through an opening in the

chest wall (open cardiac m.)– Used in cardiac arrest or Vfib

• Carotid sinus massage  – Firm rotatory pressure applied to one side of the

neck over the carotid

– Used to slow or stop tachycardia 

CPRCPR

• Cardiopulmonary resuscitation (CPR) is a combination of rescue breathing and chest compressions– victims thought to be in cardiac arrest

• 92950 

Electrophysiology (EP)Electrophysiology (EP)

• Cardiac specialty

• Concerned with mechanism, spread, and interpretation of electric currents arising within heart muscle tissue and initiating each heart contraction

Electrophysiology (EP)Electrophysiology (EP)

• Assesses cardiac arrhythmias, by– (1) measuring cardiac electrical activation/conduction– (2) assessing electrical activation patterns (mapping)– (3) inducing/terminating arrhythmias (with PES)– (4) assessing risk for malignant arrhythmias and sudden

cardiac death– (5) treating with ablation, and– (6) assessing the effects of drug and electric interventions,

including device and ablative therapies

• The approach can be either invasive or noninvasive

EP proceduresEP procedures

• Insertion sites commonly include the femoral, jugular, and, occasionally, subclavian and cephalic veins

• If necessary, femoral arteries used to gain access to the left side of heart and for continuous direct blood pressure monitoring

Radiofrequency AblationRadiofrequency Ablation

• Nonsurgical procedure to tx some types of rapid heart beats, usu. supraventricular tachyarrhythmias

• Physician guides catheter with electrode at tip to muscle with accessory (extra) pathway

• Guided with real-time, moving X-rays (fluoroscopy)• Mild, painless radiofrequency energy (similar to

microwave) is transmitted to extra pathway, destroying carefully selected heart muscle cells in a very small area (about 1/5 inch)

• 93650-93652

Cardiac Pacemakers and Pacing Cardiac Pacemakers and Pacing Cardio-fibrillators (PCDs)Cardio-fibrillators (PCDs)

• Similarities– Can be temporary/permanent

• Pulse generators implanted internally OR attached externally

– Single chamber or dual chamber• 1 lead in R heart (ventricle OR atrium)• 2 leads in R heart (ventricle AND atrium)

– Surgical approach for lead(s) placement• Epicardial –sternotomy/thoracotomy• Endocardial - transvenous

Permanent Pacemaker Permanent Pacemaker Implantation Implantation

• Recommended to correct some types of bradycardia heart blocks, afib

• A pulse generator is implanted under the skin in the upper chest or abdomen and lead wires are also attached

http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/19566.jpg

Implantable Cardioverter Implantable Cardioverter Defibrillator (ICD)Defibrillator (ICD)

• Small device implanted into the upper chest area – accurately analyze and tx

cardiac arrhythmias (ventricular)

– ICD monitor senses abnormal rhythm

– sends one + electrical impulses or shocks to heart, restoring normal rhythm

– Painful!

• Components– Pulse generator, leads, – Pacing, shocks

http://cardiophile.org/wp-content/uploads/2008/11/icd.jpg

Info Needed to Code Info Needed to Code Pacemaker/PCDPacemaker/PCD

• Single or Dual Chamber

• Epicardial or Endocardial

• Insertion– Initial, repair, replacement, upgrade

• Entire system or just a component (lead)

• Use of fluoroscopic guidance

NIPSNIPS• Non-Invasive Program Stimulation• brief procedure to adjust ICD

– heart is stimulated into a rapid heart rate– ICD delivers a shock or rapid pacing sequence to

restore a normal rhythm– Physician can then adjust the ICD's programming, if

needed – Pt is under anesthesia for the testing and able to go

home a few hours later

• 37.20 • 93642 Defibrillator, heart – Main Term

Diagnostic Vessel ProceduresDiagnostic Vessel Procedures

• Diagnostic angiography (arteriography) – 88.4x– http://www.bing.com/videos/watch/video/cardiac-angiograph

y/b2016523d08df80285dbb2016523d08df80285db-107172005295

• Doppler studies (Dopplergram, Ultrasonography) – 88.7x– http://video.google.com/videoplay?docid

=5159344335159138308# (Normal)– http://video.google.com/videoplay?docid

=5159344335159138308#docid=-3954813272712307293 (PAD)

CPT Coding of Vessel CPT Coding of Vessel ProceduresProcedures

• Selection of correct code for many procedures requires understanding of

• Appendix L – Vascular Families

• Congenital anomalies can affect order

• See resources

Vessel Proc CodingVessel Proc Coding

• endovascular Embolectomy and thrombectomy - 38.0x– w/endarterectomy – use Endarterectomy – 38.1x– "Code also”

• any thrombolytic agents injected• adjunct codes for the number of vessels treated (or if

bifurcation)

Vessel Proc CodingVessel Proc Coding

• Percutaneous transluminal (balloon)

angioplasty, peripheral artery – 39.50, 00.6x• Percutaneous transluminal atherectomy,

peripheral artery – 39.50– http://

video.about.com/heartdisease/Atherectomy.htm

• Transcatheter stenting, percutaneous

(peripheral) (non-coronary vessel – 39.90 or 00.55

Cardiac RehabCardiac Rehab

• Medically supervised program – helps improve health and

well-being

• Includes – exercise training

• EKG monitoring

– education on heart healthy living

– counseling to reduce stress

• Long-term commitment from pt and team of health care providers– doctors, nurses – exercise specialists– PTs and OTs – dietitians or nutritionists– psychologists or other

mental health specialists

Cardiac RehabCardiac Rehab

• CMS Indicators (as of 1/1/2010) MC, Part B• Statutory benefit (2008) (OIG focus)

– AMI within preceding 12 months – CABG – Current stable angina pectoris – Heart valve repair or replacement – PTCA or coronary stenting – A heart or heart-lung transplant or, – Other cardiac conditions as specified in a NCD (CR

only)

CMS RequirementsCMS Requirements

• 1) physician-prescribed exercise each day that items and services are furnished

• 2) cardiac risk factor modification • 3) psychosocial assessment • 4) outcomes assessment and • 5) an individualized treatment plan detailing how

components are utilized• Individualized treatment plan must be established,

reviewed and signed by a physician every 30 days

CMS RequirementsCMS Requirements

• Physician immediately available and accessible for medical consultations and emergencies at all times

• Non-physician practitioners such as nurse practitioners or physician assistants cannot provide direct supervision

• These requirements common problem– OIG focus

CMS RequirementsCMS Requirements

• Medical director, as well as physicians acting as the supervising physician, must possess all of the following:– (1) expertise in the management of

individuals with cardiac pathophysiology,– (2) cardiopulmonary training in basic life

support or advanced cardiac life support, and– (3) licensed to practice medicine in the state

CMS Cardiac RehabCMS Cardiac Rehab

• CR sessions are limited to a maximum of 2 1-hour sessions per day

• Up to 36 sessions furnished over a period of up to 36 weeks

• Option for an additional 36 sessions at MC contractor discretion over an extended period of time

42 CFR 410.4942 CFR 410.49

• Items and services must be furnished in physician’s office or hospital outpatient setting

• All settings must have physician immediately available and accessible for medical consultations and emergencies at all time items and services are being furnished

CMS Time RequirementsCMS Time Requirements

• Hospitals and practitioners may report a maximum of 2 1-hour sessions per day

• A 1-hour treatment must be at least 31 minutes

• 2 sessions = at least 91 minutes• If several shorter periods in a given day, the

minutes of service during those periods must be added together for reporting in 1-hour session increments

Coding Cardiac RehabCoding Cardiac Rehab

• V57.89 + code(s) for reason receiving

• 93797 - Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session) and93798 - Physician services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session) 

Billing Cardiac RehabBilling Cardiac Rehab• CR without continuous monitoring 93797

• CR with continuous monitoring 93798

• ICR with exercise G0422

• ICR without exercise G0423

• Revenue code 943 on outpatient claim using bill types 13X for OPPS and 85X for reasonable cost

• CAH – same codes used with revenue codes 096X, 097X, or 098X when billed as Method II

From First CV

Workshop

What is clubbing?What is clubbing?• Prolonged lung or cyanotic heart disease can

change other parts of the body, including finger clubbing– Lung Cancer, CHF, emphysema, smoking, – Tetralogy of Fallot

• ID by Hippocrates over 2,000 years ago• AKA – drumstick fingers, Hippocratic fingers,

watch-glass nail• http://wwwold.path.utah.edu/casepath/PM%20Cases/PMCase4/PMCase4Image7.JPG • http://www.clinicalexams.co.uk/images/finger-clubbing.gif

11stst session Homework session Homework

• Case – ID What to code?

• Case – ID What to code?

Homework for next sessionHomework for next session

• Code Identified narrative statements from two case studies

ILEMten@gmail.com

General Coding ResourcesGeneral Coding Resources

• Green, M. A. 3-2-1 Code It! 2nd ed. Delmar. 2010.

• ICD-9-CM Official Guidelines for Coding and Reporting, October 1, 2009 – http://www.cdc.gov/nchs/data/icd9/icdguide09.pdf

• Maxim HI Services. Coding Corner Newsletter.– http://www.maximhealthinformationservices.com/blog.aspx

• Moisio M. A. & E. W. Moisio, Understanding Laboratory and Diagnostic Tests, Delmar, 1998 (2nd ed? Later)

“ “Clubbing” ResourcesClubbing” Resources

• MedlinePlus. Clubbing of fingers or toes.– http://www.nlm.nih.gov/medlineplus/ency/article/003282.htm

• Merck Manuals Online Medical Library; Home edition for Patients and Caregivers. Symptoms and Diagnosis of Lung Disorders

– http://www.merck.com/mmhe/sec04/ch039/ch039b.html

Cardiac Coding ResourcesCardiac Coding Resources• Cardioversion. Doctor-reviewed article from RightHealth and A.D.A.M.

– http://www.righthealth.com/topic/Cardioversion/overview/adam20?fdid=Adamv2_007110&section=Full_Article

• Diagnosing Heart Disease With Cardiac Computed Tomography (CT). 2009.– http://www.webmd.com/heart-disease/guide/ct-heart-scan

• Doppler Echo Coding Gets a Facelift for 2009. Cardiology Coding Alert 2008: V12, No. 2

– http://www.codinginstitute.com/articles/doppler_echo_coding_gets_a_facelift.html

• MC Reimbursement for Cardiac CT and Computed Tomographic Angiography. GE Healthcare. January 2009.

– http://www.gehealthcare.com/usen/community/reimbursement/docs/CT_CTA10_2009.pdf

• Stress Test Coding. Codapedia.– http://codapedia.com/-article_233_.cfm

Cardiac Rehab ResourcesCardiac Rehab Resources• American Heart Assoc. Cardiac Rehabilitation.

– http://www.americanheart.org/presenter.jhtml?identifier=4490

• CMS Manual System. Pub 100-04, Transmittal 1974 Date: May 21, 2010 Change Request 6850. SUBJECT: Cardiac Rehabilitation and Intensive Cardiac Rehabilitation – http://www.cms.gov/transmittals/downloads/R1974CP.pdf

• Heart healthy living. Cardiac Rehab.– http://www.hearthealthyonline.com/heart-disease-overview/cardiac-rehab/

• Mackaman, D. Cardiac Rehab and Intensive Cardiac Rehab revisited. 2010.

– http://blogs.hcpro.com/medicarefind/2010/05/cardiac-rehab-and-intensive-cardiac-rehab-revisited/

• NHLBI (NIH). What Is Cardiac Rehabilitation?– http://www.nhlbi.nih.gov/health/dci/Diseases/rehab/rehab_whatis.html

CAD Coding ResourcesCAD Coding Resources

• Schnitzer, G. How to code coronary artery disease (CAD): 414.00 vs 414.01. 2007.– http://www.coderyte.com/Coding-corner/how-to-code-coronary-

artery-disease-cad-41400-vs-41401.html

• Types of Atherectomy. About.com Heart Disease.– http://video.about.com/heartdisease/Atherectomy.htm

EP ResourcesEP Resources• Programmed Electrical Stimulation. eMedicine. 2008.

– http://emedicine.medscape.com/article/163503-overview

• Radiofrequency Ablation. American Heart Association. – http://www.americanheart.org/presenter.jhtml?identifier=4682

• Cardiac Rhythm Management and Electrophysiology ICD-9-CM and CPT® Codes. February 2010.

– http://www.bostonscientific.com/cardiac-rhythm-resources/assets/downloads/reimbursement/2010/CRM-EP-ICD9-CPT-Codes.pdf

• Cardiac Rhythm Resource Center. Boston Scientific.– Webcast for Ces – no charge.– http://www.bostonscientific.com/cardiac-rhythm-resources/

reimbursement/Reimbursement-Join-GuidePoint.html?

Heart Failure Coding ResourcesHeart Failure Coding Resources

• Challenges for Coding Heart Failure. CCS Prep!. Advance for HI Professionals, 2007 – http://health-information.advanceweb.com/Article/Challenges-

for-Coding-Heart-Failure.aspx

HTN Coding ResourcesHTN Coding Resources

• Maccariella-Hafey, P. Coding of Hypertension warrants a second look. 2002. CCS Prep! Advance for HI Professionals. Vol. 12 •Issue 13 • Page 8

– http://health-information.advanceweb.com/Article/Coding-of-Hypertension-Warrants-Second-Look-1.aspx

• Test-Takers Should Become Familiar With Hypertension Coding Guidelines. CCS Prep. Advance for HI Professionals. 2005– http://health-information.advanceweb.com/Article/Test-Takers-

Should-Become-Familiar-With-Hypertension-Coding-Guidelines.aspx

Vascular Coding ResourcesVascular Coding Resources• Concentric Medical. An Introductory guide for physicians, coding

professionals and practice managers to aid in understanding coding and reimbursement for mechanical thrombectomy, embolectomy, and related neurology procedures.

– http://www.concentric-medical.com/upload_images/APM0210_E_Booklet,%202009%20Physician%20Coding%20Guide.pdf

• Determining selective vs. nonselective arterial catheter placement. 2008.

– http://www.rt-image.com/Quick_Tips_Rules_to_Choose_By_Determining_selective_vs_nonselective_arterial_cat/content=8004J05E48B68484407698744468A0441

• Put Your First - Second-Order Proficiency to This PV Case Study Test. Cardiology Coding Alert. 2008, v. 11, No. 12 – http://www.codinginstitute.com/articles/Put_Your_First_Second-

Order_Proficiency_to_This_PV_Case_Study_Test.html