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1 CODING COMPANION 2018 Cardiology/ Cardiothoracic/ Vascular Surgery A illustrated guide to coding and reimbursement POWER UP YOUR CODING with Optum360, your trusted coding partner for 32 years. Visit optum360coding.com.

2 Contents Getting Started with Coding Companion...i Chest Wall... 1 General Musculoskeletal... 2 Neck and Thorax... 5 Larynx Trachea and Bronchi Lungs and Pleura Heart and Pericardium Arteries and Veins Lymph Nodes Mediastinum Diaphragm Esophagus Abdomen Thyroid Gland Parathyroid Nervous System Medicine HCPCS Appendix Correct Coding Initiative Update Evaluation and Management Index Coding Companion for Cardiology/Cardiothoracic/Vascular Surgery Contents i

3 Getting Started with Coding Companion Coding Companion for Cardiology/Cardiothoracic/Vascular Surgery is designed to be a guide to the specialty procedures classified in the CPT book. It is structured to help coders understand procedures and translate physician narrative into correct CPT codes by combining many clinical resources into one, easy-to-use source book. The book also allows coders to validate the intended code selection by providing an easy-to-understand explanation of the procedure and associated conditions or indications for performing the various procedures. As a result, data quality and reimbursement will be improved by providing code-specific clinical information and helpful tips regarding the coding of procedures. For ease of use, Coding Companion lists the CPT codes in ascending numeric order. Included in the code set are all surgery, radiology, laboratory, medicine, and evaluation and management (E/M) codes pertinent to the specialty. Each CPT code is followed by its official CPT code description. Resequencing of CPT Codes The American Medical Association (AMA) employs a resequenced numbering methodology. According to the AMA, there are instances where a new code is needed within an existing grouping of codes, but an unused code number is not available to keep the range sequential. In the instance where the existing codes were not changed or had only minimal changes, the AMA assigned a code out of numeric sequence with the other related codes being grouped together. The resequenced codes and their descriptions have been placed with their related codes, out of numeric sequence. CPT codes within the Optum360 Coding Companion series display in their resequenced order. Resequenced codes are enclosed in brackets for easy identification. ICD-10-CM Overall, the 10th revision goes into greater clinical detail than did ICD-9-CM and addresses information about previously classified diseases, as well as those diseases discovered since the last revision. Conditions are grouped with general epidemiological purposes and the evaluation of health care in mind. New features have been added, and conditions have been reorganized, although the format and conventions of the classification remain unchanged for the most part. Detailed Code Information One or more columns are dedicated to each procedure or service or to a series of similar procedures/services. Following the specific CPT code and its narrative, is a combination of features. A sample is shown on page ii. The black boxes with numbers in them correspond to the information on the page following the sample. Appendix Codes and Descriptions Some CPT codes are presented in a less format in the appendix. The CPT codes appropriate to the specialty are included in the appendix with the official CPT code description. The codes are presented in numeric order, and each code is followed by an easy-to-understand lay description of the procedure. The codes in the appendix are presented in the following order: Category III Radiology Pathology and Laboratory Medicine Services Category II codes are not published in this book. Refer to the CPT book for code descriptions. Coding Companion for Cardiology/Cardiothoracic/Vascular Surgery CCI Edit Updates The Coding Companion series includes the list of codes from the official Centers for Medicare and Medicaid Services National Correct Coding Policy Manual for Part B Medicare Contractors that are considered to be an integral part of the code or mutually exclusive of it and should not be reported separately. The codes in the Correct Coding Initiative (CCI) section are from version 22.3, the most current version available at press time. The CCI edits are located in a section at the back of the book. Optum360 maintains a website to accompany the Coding Companions series and posts updated CCI edits on this website so that current information is available before the next edition. The website address is The 2017 edition password is: SPEC17DLC. Please note that you should log in each quarter to ensure you receive the most current updates. An reminder will also be sent to you to let you know when the updates are available. Evaluation and Management This resource provides documentation guidelines and tables showing evaluation and management (E/M) codes for different levels of care. The components that should be considered when selecting an E/M code are also indicated. Index A index is provided for easy access to the codes. The index entries have several axes. A code can be looked up by its procedural name or by the diagnoses commonly associated with it. Codes are also indexed anatomically. For example: Transmastoid antrotomy (simple mastoidectomy) could be found in the index under the following main terms: Antrotomy Transmastoid, Excision Mastoid Simple, General Guidelines Providers The AMA advises coders that while a particular service or procedure may be assigned to a specific section, the service or procedure itself is not limited to use only by that specialty group (see paragraphs two and three under Instructions for Use of the CPT Codebook on page xii of the CPT Book). Additionally, the procedures and services listed throughout the book are for use by any qualified physician or other qualified health care professional or entity (e.g., hospitals, laboratories, or home health agencies). Keep in mind that there may be other policies or guidance that can affect who may report a specific service. Supplies Some payers may allow physicians to separately report drugs and other supplies when reporting the place of service as office or other nonfacility setting. Drugs and supplies are to be reported by the facility only when performed in a facility setting. Professional and Technical Component Radiology and some pathology codes have a technical and a professional component. When physicians do not own their own equipment and send their patients to outside testing facilities, they should append modifier 26 to the procedural code to indicate they performed only the professional component. Getting Started with Coding Companion i

4 Explanation Removal of percutaneous ventricular assist device at separate and distinct session from insertion A ventricular assist device (VAD) bypasses the left ventricle during the blood oxygenation cycle making the ventricle work less during the systolic phase. The device is removed when the patient's ventricle recovers, an artificial heart is placed, or the patient undergoes heart transplantation. The catheters are removed from the left atrium and one or more femoral vessels and the external centrifugal assist device is discontinued and removed. This code can only be reported for the removal of a VAD during a different operative encounter than the insertion, and is only used for a percutaneous VAD, not an implantable VAD. Coding Tips This code has been revised for 2017 in the official CPT description. The moderate sedation icon has been deleted. For insertion of the percutaneous ventricular assist device, see For repositioning of the percutaneous ventricular assist device, see For removal of implantable intracorporeal ventricular assist devices, see For removal of extracorporeal ventricular assist devices, see For removal of implantable aortic counterpulsation ventricular assist system, see 0455T-0458T. ICD-10-CM Diagnostic Codes T82.518A T82.528A T82.538A T82.598A T82.7XXA T82.817A Breakdown (mechanical) of other cardiac and vascular devices and implants, Displacement of other cardiac and vascular devices and implants, Leakage of other cardiac and vascular devices and implants, Other mechanical complication of other cardiac and vascular devices and implants, Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, Embolism due to cardiac prosthetic devices, implants and grafts, T82.827A T82.837A T82.847A T82.857A T82.867A T82.897A T82.898A Z45.09 Z Fibrosis due to cardiac prosthetic devices, implants and grafts, Hemorrhage due to cardiac prosthetic devices, implants and grafts, Pain due to cardiac prosthetic devices, implants and grafts, initial encounter Stenosis of other cardiac prosthetic devices, implants and grafts, Thrombosis due to cardiac prosthetic devices, implants and grafts, Other specified complication of cardiac prosthetic devices, implants and grafts, Other specified complication of vascular prosthetic devices, implants and grafts, Encounter for adjustment and management of other cardiac device Presence of heart assist device HCPCS Equivalent Codes Terms To Know extracorporeal. Located or taking place outside the body. moderate sedation. Medically controlled state of depressed consciousness, with or without analgesia, while maintaining the patient's airway, protective reflexes, and ability to respond to stimulation or verbal commands. percutaneous. Through the skin. ventricular assist device. Temporary measure used to support the heart by substituting for left and/or right heart function. The device replaces the work of the left and/or right ventricle when a patient has a damaged or weakened heart. A left ventricular assist device (VAD) helps the heart pump blood through the rest of the body. A right VAD helps the heart pump blood to the lungs to become oxygenated again. Catheters are inserted to circulate the blood through external tubing to a pump machine located outside of the body and back to the correct artery. Medicare Edits Fac RVU Non-Fac RVU * with documentation 5.84 Modifiers 80 FUD Status A MUE 1(2) Medicare Reference None Heart and Pericardium Coding Companion for Cardiology/Cardiothoracic Surgery/Vascular Surgery Heart and Pericardium 357

5 Hospital Inpatient Services Initial Care 1 Evaluation and Management E/M Code History 2 Exam 2 Making Detailed or Detailed or 1 The admitting physician should append modifier AI, Principal physician of record, for Medicare patients 2 Key component. For initial care, all three components (history, exam, and medical decision making) are crucial for selecting the correct code. Hospital Inpatient Services Subsequent Care 1 1 All subsequent levels of service include reviewing the medical record, diagnostic studies, and changes in the patient s status, such as history, physical condition, and response to treatment since the last assessment. 2 Key component. For subsequent care, at least two of the three components (history, exam, and medical decision making) are needed to select the correct code. Observation or Inpatient Care Services (Including Admission and Discharge Services) 1 Key component. All three components (history, exam, and medical decision making) are crucial for selecting the correct code. Low Comprehensive Comprehensive Moderate complexity Moderate Comprehensive Comprehensive High complexity High E/M Code History 2 Exam 2 Making Problem-focused interval Expanded problem-focused interval Problem-focused Expanded problem-focused Moderate complexity Stable, recovering or Improving Inadequate response to treatment; minor complications Detailed interval Detailed High complexity Unstable; significant new problem or significant complication Time Spent Bedside and on Unit/Floor (avg.) 30 min. 50 min. 70 min. Time Spent Bedside and on Unit/Floor (avg.) Hospital discharge day management 30 min. or less Hospital discharge day management > 30 min. E/M Code History 1 Exam 1 Making Detailed or Detailed or Low Comprehensive Comprehensive Moderate Moderate Comprehensive Comprehensive High High 15 min. 25 min. 35 min. 40 min. 50 min. 55 min. Time 962 Evaluation and Management Companion for Cardiology/Cardiothoracic/Vascular Surgery