Hi, this is Nicole Knight with MedAxiom Revenue Cycle Solutions. For our session in the Cardiovascular Coding Education Series, we're going to cover common cardiovascular terminology and anatomy. Our hope is to provide the basics that assist with the coding applications you'll be applying throughout the series. The basics of the medical terminology and anatomy are related to the cardiovascular system, and it is important as you learn in coding and in selecting the appropriate diagnosis code or procedure code, those foundations of the principles are based on medical terminology, anatomy, diseases, and of course, many of the abbreviations and other forms that we use to apply those principles and guidelines. So let's start off with the cardiovascular medical terminology. Just a few facts and tips. 75% of the medical terms are based on either Greek or Latin. They indicate frequently a body part. They are one or more root words. Most medical terms have one or more words or roots. The study of the origin of words is called etymology. Not all medical terms are derived from word parts. So some of these facts we all will see as I go through some of the terminology. It does apply many of what we've learned from English and also from math, which was a bit surprising as we put the words together. The form of roots, when we say cardia in the Greek term, it has a K, and the root word in our world would be cardia with a C. And that is the form of the word that represents heart. And they do have these roots for stomach, liver, kidney, bone. There's several of them, but as you go through the coding principles, you'll see from the root word, cardia, gastro, hepa, nephra, osteo, they will all point you in the direction of the body part, the heart, stomach, liver, kidney, or bone. When you look at combining it, and this is what I was talking about when I started putting this presentation together, looking at the combining form is the word root plus a vowel, which is usually O. So in the cardiovascular world, much of our reports have cardio, which relates to heart, angio, which relates to a vessel, aorta, which relates to the aorta, and then corona, which is the coronary artery, and then my plus O, which is myo for muscle. So as you begin to break these terms up, that first part of the root word and adding an O identifies the particular anatomy that we're referring to. The suffixes and prefixes, when you're talking about medical terminology, the suffix is the word ending that indicates the procedure, condition, disease, or part of a speech. For prefix, the word beginning, it's the word beginning and changes the meaning of the word. So that prefix would indicate a number, time, position, direction, color, or sense. So when we're looking at cardiovascular examples of the suffix and the prefix, and this is when it becomes relative to our CPT professional codes for cardiovascular conditions, you can see that IC refers to pertaining to, also TIC refers to pertaining to, and then when you look at the others here, such as osus or otomy, those would represent different types of conditions, or otomy, which is cutting into, ostomy, which is the formation of an opening. And then you add that to a prefix, so if you add that suffix to the prefix, hyper, which would be excessive, inter, between, intramedal, medial, peri, which is round, and then endo, which is within or inside, as some examples, these become very important as you get into our peripheral vascular coding section and looking at the direction of the catheters and where the physician may be placing that catheter in order to perform angiography, which is imaging of that vessel, and providing those results within the report. This will help in leading to the code selection. So when we talk about cardiovascular, we have various specialties or subspecialties under the term of cardiology. So when you look at cardiology, it refers to, cardia refers to the heart, ology refers to the study of, so when you put that word together, it makes cardiology, which is the study of the disorders of the heart. You can do the same thing when you relate it to the specialties or subspecialties. When you take the cardia and you add ologist, this is someone who specializes in the disorders of the heart, a cardiologist. When you add interventional to that cardiologist, that's someone who performs advanced cardiac procedures such as catheter-based procedures that we would see done in our cath lab. Cardiac surgeons perform those major procedures of the heart and vessels. The majority of those procedures, unlike the interventionalist, are open procedures. The interventionalist is generally doing them percutaneous. For electrophysiologists, you can break that down. Electro refers to electricity, physio means physiology, ologist refers to who studies it. So an electrophysiologist is truly looking at the body's electrical and biological functions. We often call them the electrician. We call our interventional cardiologists the plumbers. Just a little reference there of those terms. Now we're going to cover some anatomy and physiology. This is not all inclusive of the cardiovascular system, but it's to serve as just a basic foundation for you to apply the coding principles. There are several online resources provided that do offer more in-depth anatomy and physiology, but we wanted to touch on those key areas as part of this education foundation series. So what is the cardiovascular system? The cardiovascular system is the transport system of the body. The heart is the system's pump, and the blood vessels are like the delivery route. There are three main components, the heart, the blood vessels, and the blood itself. The blood can be thought of as the fluid, which contains the oxygen and nutrients the body needs and carries the waste which need to be removed. So again, that cardiovascular system, if you think of it as our transport system, and often when we're describing our CPP codes for invasive procedures such as peripheral vascular or cath lab or even EP, we're talking about what are those intersections, what is the transport system, where is the blood flowing, where are the catheters placed, and so on. So we're going to look at the anatomy of the heart, the location, which is in the thoracic cavity, the coverings that protect the heart, the four chambers, the heart valve, the coronary circulation, and then the output, conduction, or physiology. So as we talk about these, when we look at the size, location, and orientation, the heart is enclosed in the mediastinum, the base is the posterior superior portion, and the apex is the inferior anterior portion. When you're coding cardiovascular services, the physician will often document if they are accessing a site inferior, anterior, posterior, superior, so it's important to know where did they start and where did they finish. The coverings of the heart, the pericardium protects the heart. It anchors the heart to the surrounding structure such as the diaphragm. It prevents overfilling of the heart with blood. The epicardium is part of the heart wall, which is a serous membrane that forms the innermost layer of that pericardium and the outer surface of the heart. So you think about it being that innermost layer that is providing that protection. The myocardium is the bulk of the heart consisting mainly of the heart muscle. So when we look at heart function, we're looking at that myocardium, which is that heart muscle. The endocardium is the thin smooth membrane which lines the inside of the chambers of the heart and forms the surface of the valve. So we have the innermost layer, which is the epicardium, we have the muscle layer, which is the myocardium, and then we have that smooth thin layer that gives us the inside of the chamber and forms the surfaces of the valve. When we look at the heart chambers, we have the right atrium, which as we talk about that transport system, receives oxygen poor and returns the blood to the heart from the circulation. So these receiving chambers of the right atrium for blood, which is oxygen poor at this functioning part, return to the heart from the circulation. The left atrium pumps the blood, which is our oxygen-rich blood, from the lungs to the left ventricle, and then the left ventricle pumps oxygen-rich blood to the body. The left ventricle is three times thicker than the right. The right ventricle pumps the oxygen poor blood to the lungs. So when you look at your left and right ventricle, you're truly looking at that pumping function as we do when we do echocardiograms. So any anatomy pictures will be in blue or red. The blue indicates oxygen poor blood, and the red is the oxygen-rich blood. So that helps when you look at these different models and the location of how this is pumped throughout the heart and through that transport system of the oxygen-rich and the oxygen poor blood to the lungs. For the heart valve, our valves ensure that the blood flows through the heart correctly. They open and close in response to different pressures on either side. They perform this function and are made up of flax that open and close along with the rhythm of the heart. So if you think not only about the blood flow with the valves and the opening and closing, you also think about that function of the heartbeat, which provides the rhythm of the heart. So when we talk about those electricians, the electrophysiologists, their concern is the rhythms of the heart. And then when we look at our cardiologists or interventional cardiologists, it's the function of the heart, which is their primary specialty. And looking at truly how that structural piece of the heart works in ensuring that that blood flows from the heart in the correct manner. Our atrioventricular valves simply mean that they are located between the atria and the ventricle. These are our tricuspid and mitral valves. The tricuspid valve is located between the right atrium and ventricle. When it's closed, it allows oxygen-depleted blood returning to the heart from the vena cata to fill that right atrium. And it prevents the backflow of blood that is pumped from the right atrium to the left ventricle. When it's open, it allows blood from the right atrium to flow into the right ventricle. For the mitral valve, it is located between the left atrium and ventricle. When closed, it allows the left atrium to fill with oxygen-rich blood returning to the heart from the pulmonary vein. And then when it's open, it allows the blood from the left atrium to fill that left ventricle. Our semilunar valves. The definition of these valves are flaps of the endocardium and connective tissue reinforced by fibers which prevent the valves from turning inside out. So somewhat like the shape of the half moon, which is where that term semi and lunar comes from. It's located between the aorta and the left ventricle and between the pulmonary artery and the right ventricle. So when you look at the pulmonary valve, it's between the right ventricle and pulmonary artery. When closed, it prevents the backflow of the blood pumped from the right ventricle to the pulmonary artery. When open, it allows the oxygen-depleted blood from the right ventricle to the pulmonary artery. The aorta is located between, so this would be our aortic valve, between the left ventricle and the aorta. When closed, the blood from the left atrium is allowed to fill the left ventricle and prevent the backflow of blood. And when it's open, that oxygen-rich blood flows to the aorta and the rest of the body. So the aorta carries the blood to the rest of the body. The aortic valve is what's located to prevent that backflow of blood. So when we think about that semi-lunar half moon, those flaps that reinforce with those connective tissue to prevent that backflow of blood as it's pumped throughout the body. From a coronary circulation standpoint, the blood is supplied to the heart by its own vascular system, which is our coronary circulation. The circulation of blood in the blood vessels that supply the heart muscle then the coronary arteries that supply the oxygenated blood to the coronary muscle, the cardiac veins, that drain away the blood once it's deoxygenated. So as we think about the work of those chambers, the heart wall, how the blood functions throughout coronary circulation, this is when we see that transport system occurring of the oxygenated and the deoxygenated blood throughout the body. So what are some types of blood vessels? Common with coatings, we are coating for blood vessels in the arteries and veins normally. And those arteries carry the oxygenated blood from the heart to the rest of the body. They have elastic walls that help keep that blood pressure consistent. And they branch into smaller arterioles. For veins, they carry the deoxygenated blood back to the heart and increase in size as they get closer. And they have thinner walls than arteries. So the arteries are powerful elastic walls carrying that blood with consistent pressure from the heart to the rest of the body and the veins have those thinner walls which are bringing that deoxygenated blood back to the heart. The capillaries connect the smallest arteries to the smallest veins. So very thin small walls which allow to exchange compounds into tissues such as carbon dioxide, water, oxygen, waste, and nutrients. This is related to our cardiac output. The primary coronary arteries are the right main referred to as the RCA that sends blood to the right side of the heart and it includes the right ventricle and the atrium. The left main sends the blood to the left side, which is the ventricle and the atrium of the heart muscle. on that left side. The left circumflex LC circles around the heart muscle. This artery sends blood to the outer side and the back of the heart. The left anterior descending the LAD sends blood to the front of the left side of the heart and helps send the blood to the middle or septum of the heart. So as we perform coronary intervention procedures our physicians are selecting generally four to five of the main coronary arteries that supply the heart with blood. We'll talk a little bit when we get to the coding section about that fifth artery that not all patients have and it's called a ramus. These are the four coronary arteries and these are what provides blood, sends that blood to portions of the heart and the septum as well. When we look at the transport system, it all starts in the aorta and then when we get to those coronary arteries, our LAD or our left circumflex is part of the left coronary artery system. Our right coronary artery includes marginal branches that supply the left ventricle, also includes posterior descending branches that supply the left ventricle, and then when you look at that left system as well, the LAD or the left anterior descending routes off into diagonal branches that supply the septum. The circumflex splits to marginal branches that also supply the free wall of that left ventricle. So you can see how it's all intertwined within those coronary arteries. So when we talk about blockages and if any of these arteries are blocked on the left or the right system, depending on the percentage, how that can decrease the oxygenated blood to the heart and cause damage ultimately to the heart wall or the heart muscle. When you're coding for coronary interventional procedures, you will use the terminology of the LAD, the diagonal, the circumflex, the marginal, the right coronary artery, the posterior descending coronary artery, or the inferior descending coronary artery, the marginal branches. So it will touch all of these vessels from a coding standpoint. In this graphic, again, it's showing that flow of the oxygenated to the deoxygenated blood to and from the heart to the body and the output of that. Using graphs does help tremendously as you're coding for sections of the body. From a cardiac output perspective, this is the measurement of the amount of blood pumped by each ventricle in one minute. It's calculated by multiplying the stroke volume by each ventricle by the heart rate in contractions per minute. So when we look at our blood pressure output, this may be related to that stroke volume, the heart pumped, and then we'll talk about more around the heart rate when we're looking at EKGs or our electro recordings of the graphs of the heart. Exercising increases our cardiac output deficiency, and the difference between maximum and resting cardiac output is known as that cardiac reserve. So this measures that residual capacity of the heart to pump the blood. There are several factors that affect our heart rate and our stroke volume. So when you look at, for example, our heart rate, our fitness level, we know when we exercise, our heart rate goes up. So that impacts our heart rate, which will affect our stroke volume as well and the contractibility of the heart, the duration of the contraction. And when this is calculated, again, using that mathematics, that cardiac output equals the heart rate times that stroke volume. When we're looking at this output, specifically important for our congestive heart failure patients and looking at their ejection fraction, which is that of the percentage of that cardiac output flowing through the heart. The conduction system. The conduction system is a collection of nodes and specialized cells that initiate and coordinate contraction of the heart muscle. Consists of the sinoatrial node, which is our SA node, the atrioventricular node, which is our AB node, and the bundle of the atrioventricular, which is the bundle of his, and then Purkinje fibers. These provide the heart its automatic rhythmic beat. So this is where our electrophysiologists live within this space. When you look at the electrical system of the heart, we're going to talk about how the signals are sent through the heart to conduct the beat of our heart and our heart rhythm. So conduction of those electrical impulses. The impulses are generated by a group of specialized pacemaker cells. So the SA node is referred to as our personal pacemaker. They spread through the entire right and left atrial muscle, triggering a contraction of the right and left atrium. They travel to the AB node. This is where the speed here is slow or delayed. The delay allows time for that atria to finish its contraction and empty into the ventricles before the contraction. Travels from the AB node to the ventricles. Here, the left and right branch of the bundle of his is where those are impulses are received. After the delay at the AB node, the impulses rapidly rapidly spread to the ventricles via the specialized fibers called Purkinje fibers. So that electrical impulse is flowing from the SA node to the AB node. So it's going from the atrium to the ventricle to the bundle of his, then to the Purkinje fibers. And that's what's creating our electrical impulse. So when we look at our electrocardiograph, which is our EKG or referred to as our ECG, these are when small electrodes are attached to the body, generally called a 12-lead EKG. And you're looking for the consequence of the cardiac muscle to deploralize, followed by reploralization during each heartbeat or cardiac cycle. Then it generates a recording or graph of the voltage versus the time that it took for that electrical activity of the heart using the electrodes placed on the skin. There's three main components to the EKG. The P-wave, which represents that deploralization of the atria. The QRS complex, which represents the deploralization of the ventricles. And the T-wave, which represents the reploralization of the ventricles. As we look at diagnostic testing and also diagnosis coding, the P-wave, QRS complex, and T-waves are referred to in documentation as to a particular arrhythmia or condition based on that conductive pattern. So this is an example of an EKG. When you look at that P-wave, the P-wave has that deploralization into the SA node. So remember that starts our personal pacemaker. The PR interval, which is between the P and the R. So it's the start of that QRS complex. The time impulse, the PR interval, the time impulse travels from the SA node to the AV node. So we're going from the atrium to the ventricle. That QRS complete complex is that rapid deploralization of the right and left ventricles in the bundle of his. And then that T-wave is that repolarization of the ventricle. So when it's in that QRS complex, it's going through the bundle of his, the Purkinje fibers, and then that repolarization of the ventricle. So each heartbeat is referred to as diastole or systole. So, you know, when we take blood pressure, we're looking at diastolic and systolic blood pressure. For diastolic, it's the atria and ventricles relax and fill with blood. And in the systole, the atria contract and push blood into the ventricles. Then as the atria start to relax, the ventricles contract and pump blood out of the heart. So now that we've talked about some of the common functions of the heart, both electrical and foundational to the heart, we're going to talk about some of the cardiovascular conditions. So this is not an all-inclusive list, but are some of the most common. Coronary artery disease or myocardial infarction, heart valve disease, heart failure, heart muscle disease, which is known as cardiomyopathy, abnormal heart rhythm or arrhythmias, peripheral artery disease, which is known as PAD or PVD. And we have several abbreviations for abnormal heart rhythms, for our myocardial infarctions and all of those. Having a good resource to refer to for your abbreviations is important. And Google is always our friend in this area. If you look up medical abbreviation and put in that, the technology is great that it can pull several resources that direct you to the correct interpretation of those acronyms. So let's talk about coronary artery disease known as CAD. Also, this could be called atherosclerosis and arteriosclerosis when you're looking at diagnosis coding. So you'll hear some about that when we get into the ICD-10 diagnosis coding section. But CAD is a common term for the buildup of plaque in the arteries of the heart that can lead to a heart attack. It grows within the walls of the coronary arteries until the blood flow of the muscles limited. This is called ischemia. So sometimes you'll hear ischemic heart disease all under the premise of coronary artery disease. It may be chronic narrowing of the coronary artery over time, which begins to limit that blood supply to part of the muscles of the heart. When it's in its acute phase, it results in a sudden rupture of that plaque and formation of a thrombus or blood clot. This is what we consider a heart attack or M.I. myocardial infarction. There are many risk factors associated with coronary artery disease, such as high cholesterol, commonly referred to as high LDL or low HDL, high blood pressure, known as hypertension, family history, diabetes, smoking, obesity, many risk factors that are documented along with coronary artery disease and coded as part of the patient's condition. Typical warning signs are chest pain, shortness of breath, palpitations, fatigue, and there's several other warning signs, but these are the most common. When we talk about myocardial infarction, we will hear S.T. elevation M.I. or STEMI, S.T. depression or non-STEMI, or non-STEMI with a T inversion. These are all related to our EKG and the rhythms of the heart. So, looking at that conduction system and where it's faulty. So, when you look at a patient's EKG, you can determine, physician can determine what type of M.I. that may be present based on that patient's EKG. A myocardial infarction occurs when a blockage in one or more coronary arteries reduces or stops blood flow to the heart. This is what starts that oxygenation of the blood to the heart. The blockage could be partial, which is considered a non-STEMI or complete, which is considered a STEMI. Common treatment or thrombolysis, PCI, or thrombolysis, PCI, percutaneous coronary intervention, which are our stents, balloon angioplasties, arthrectomies, so on, up to what we say is CABG, which is our open heart bypass procedure. Common medications you may see are aspirin, clavix, beta blockers, anticoagulants, cholesterol medicines, ACE, ARB, diuretics, several different medications for our myocardial infarction patients, and some will be on some of these for life. So, when we look at the common myocardial infarction and CAD coding information, there's several ICD-10 codes that describe the specific type, location, and cause of these conditions. So, it's crucial in the documentation to have those key elements to get to the specificity needed for your diagnosis code. In our CPT book for the procedure codes, we're going to be looking for those PCI, or interventional procedures, for an acute MI, a chronic total occlusion, a bypass, a stent. The amount and location of a stent is important because it does drive your code. If you go back to our primary coronary arteries, the LAD, RCA, circumflex, left main, all of those, and knowing where that occlusion is, stenosis, or where the procedure is performed are important to selecting your code. Also, those risk factors we talked about are very important to capture. You want to paint the picture of your patient's condition and what was required to treat that patient to substantiate the medical necessity coded on the claim form for these conditions. Heart valve diseases. One or more of the valves in the heart doesn't work properly. So, we talked about the open and closing. So, in some cases, one of these valves may not open or close, or maybe two or more of these valves may not open and close. This causes the blood flow of the heart to the body to be disrupted. And when you look at heart valve disease treatment, it depends on what valve is affected and the type and severity of that valve disease. Common symptoms generally are heart murmur, chest pain, swelling, shortness of breath, dizziness, or fainting. Many of these signs and symptoms, as you know, can be relative of many cardiovascular conditions. So, very important when the provider is describing in the history of the present illness on their E&M visit encounters, they're giving us that information on those symptoms as they're formulating their diagnosis. Treatment for heart valve disease varies from medical to surgical repair and replace. There are several advances in technology in cardiovascular procedures where now we can do transcatheter valve replacement as opposed to open procedures. These are done on a higher risk patient population, which has advanced medicine greatly for our elderly population who are active and able to function at a higher level. Medication management is often part of this, but inevitably some may need to repair or completely replace their valve through open surgery, which is done by our cardiothoracic surgeons. So, heart valve problems that you may see documented are regurgitation, which is when the valve flaps don't close properly and they cause a leak back into the heart. Generally, the valve flaps are bulging back and called a condition called prolapse. So, I know we've all heard of mitral valve prolapse. Stenosis is when they become thick or stiff and they may fuse together so they have a narrow opening, which reduces the blood flow through that valve. Then atresia is when it's not formed and a solid sheet of tissue can totally block the flow between the heart chambers. That, of course, would be more of our open procedures to formally replace our valve. Common valve information. So, we know that we have our four valves, mitral, trituspic, aortic, and pulmonary. You could have single or multiple valve disease. So, when you're coding for these valves, there's several diagnostic or diagnosis coding principles related to coding. If it's a single valve, a multiple valve, if it's rheumatic versus non-rheumatic. So, it's important to have those key details. Then the procedures for these are usually diagnostic. So, most patients who have any type of valve abnormality would show on an echocardiogram as an example. Then it could go to a more invasive approach as we talked about if they have to require open treatment or percutaneous valve replacement. So, common procedures refer to our TEEs, our transesophageal echoes, our echocardiograms of the transthoracic, right heart cath, which gives us our cardiac output pressures, our left heart cath, which is looking at our coronary arteries, et cetera, CAVR, which that's our transcatheter aortic valve replacements that we talked about, that it was a newer technology, open valve replacement and repair, and then we have some percutaneous procedures also known as mitral clip or TMVR, which is the same as our TAVR, just of the mitral valve. So several advances in this area from a valve replacement standpoint, and many procedure codes exist in this area, both for open and transcatheter procedures. A lot of the CPT codes start off as a temporary code, which does present some coding challenges. So as this technology continues to evolve, you wanna be sure that you're keeping up with that technology, terminology, and what's happening with these conditions. Heart failure. Heart failure is a chronic progressive condition in which the heart muscle is unable to pump enough blood to meet the body's need for blood and oxygen. The heart tries to compensate, which causes it to enlarge and pump faster, which increases the output and the mass. The blood flow out of the heart flows, blood returning to the heart through the veins, backs up, causing congestion. So this is when we talk about swelling or edema. Heart failure can involve the heart's left side, right side, or both sides. Common term congestive heart failure is a type of heart failure, although the terms heart failure, congestive heart failure, diastolic failure, there's many interchangeable terms when you talk about heart failure. At times, the fluid collects in the lungs and interferes with breathing, causing shortness of breath and that pulmonary edema. So if you think about the heart is trying to overcompensate by pumping faster, which is increasing the output, so the output is causing us to have this fluid overload, which interferes with our breathing, our heart rate, our activity levels, and several different factors. Types of heart failure are very important as you code for diagnosis coding. This is one area in diagnosis coding that is the most unspecified diagnosis code across systems in our healthcare to get to that level of specificity for patients. So when you look at left-sided heart failure, the failure to properly pump out blood to the body, there's two types. Heart failure with a reduced ejection fracture, which is our EF, which is called a systolic failure. Heart failure with preserved EF is called diastolic heart failure. For right-sided heart failure, the backup in the area that collects the used blood, so that right-sided or right ventricle heart failure occurs as a result of left-sided failure. So again, we're talking some patients may have acute heart failure, chronic heart failure, acute on chronic left-sided and right-sided heart failure. The left ventricle fails on our right-sided heart failure to increase fluid pressure transferred back through the lungs, and this ultimately damages that right side of the patient's heart. So some common coding. We talked about the unspecified diagnosis. The key is knowing if it's systolic or diastolic, if it's acute chronic, acute on chronic. It's important that the provider provides this information. As coders, we can't determine that just based on that ejection fraction or simple terms. Having the physician describe the type of heart failure is critical in capturing the appropriate diagnosis code. It is prioritized in many of our risk adjustment and MCC and CC impacts. So when we talk about MCCs and CCs, these are our major complications and comorbidities or our complications and comorbidities that impact that length of stay of patients in the hospital. And risk adjustment, of course, factors in how sick are our patients and what is their cost of care. This is reflective of the claims data. So when you look at correctly coding diagnosis for heart failure, it impacts that risk adjustment score. It can also impact that DRG payment to the hospital system and the length of stay penalties for that patient. Treatments for heart failure are generally long-term, and programs have specialized heart failure clinics to manage these patients. You'll often hear about this in many of our programs. They have heart clinics where they're managed by nurses, nurse practitioners, PAs, and ultimately supervised by the physician where patients are either having remote monitoring, they're coming into clinics, and they're being managed to keep those patients out of the hospital and well. The overall goal is to reduce the readmission. There are many initiatives that occur to support heart failure from a coding standpoint. There's been new codes that have been created in CPT for transitional care management, remote care monitoring, and chronic care management. These are designed to support the patient from the time of discharge long-term if they have two or more chronic conditions. Remote patient monitoring provides the patient with the equipment at home where they can submit those readings to these clinics to provide their care, all in support of our overall goal to reduce that readmission. Cardiomyopathy refers to diseases of the heart muscle. They have many causes and signs and symptoms as well as treatments. The cause of the heart muscle to become enlarged, thick, or rigid. So you may hear about enlarged heart. That is our cardiomyopathy. Cardiomyopathy, when it worsens, the heart becomes extremely weaker. It becomes very weak. It becomes less able to plump the blood throughout the body and incapable of maintaining that normal electrical pattern. It results in heart failure or arrhythmias or potentially heart valve problems. So you may have a patient who has congestive heart failure, cardiomyopathy, atrial fib, and also have an aortic valve disorder. Very common for that. There are many types of cardiomyopathy. These are some of the main types. Dilated, hypertrophic, restrictive, arrhythmogenic, or peripartium. Others that are unclassified that we hear occasionally are broken heart syndrome. This is known as stress-induced cardiomyopathy. So when you think about a broken heart and the additional stress that that may put on the heart, that's considered cardiomyopathy if it results in a condition that is enlarging the heart, slowing that electrical pattern. It can be inherited or acquired. Cause may also be unknown, and it does affect all ages. We've talked a little bit about the ejection fraction, or our EF. This is the measurement expressed as a periaptic, of how much blood the left ventricle pumps out with each contraction. The ejection fraction of 60% means that 60% of the total amount of blood in the left ventricle is pushed out with each heartbeat. The normal EF is 50 to 70%. EF under 40% is low and may be evidence of heart failure or cardiomyopathy. So again, we're talking about that pump of the heart that is with each contraction or each rhythmic electrical conduction of the heart. And if that is low, we know it can result in potentially heart failure or cardiomyopathy. If it's higher, it may indicate the hypertrophic cardiomyopathy. So a different type of cardiomyopathy. So it's important that this EF is monitored and managed. When you look at EF in diagnosis coding, it's generally examined by echo, although it is reported on several other imaging modalities, nuclear studies, CAT scans, even our left heart cath will show and report that ejection fraction if they do some pressures associated with the right or left heart caths that we perform. There's two EF related scenarios. Preserved EF, which is referred to as our diastolic heart failure, where the heart muscle contracts normally, but the ventricles do not relax as they should during that ventricular filling. A reduced EF is referred to as our systolic heart failure, where that heart muscle does not contract effectively and therefore less oxygen rich blood is pumped out of the body. Again, we're relying upon our providers to provide us with the information in regards to coding the diagnosis. So based on what the physician documents is when you can code diagnostic heart failure or systolic heart failure. Us just knowing if it's a preserved EF or reduced EF is not really clear in the documentation. We need to know if it's diastolic or systolic. Common coding for cardiomyopathy. Treatments may vary, including medications, lifestyle, surgery, implanted devices. There are Medicare, CMS, National Coverage Determination for device procedures that have evolved such as an implantable defibrillator that may be implanted for ischemic cardiomyopathy. Documentation of comorbidities impacting the care of the patient is important and they do require long-term management with diagnostic studies. And of course, if you have an implantable device, that device is being consistently monitored and that heart function EF is monitored on a continuing basis, whether it's through an echocardiogram, heart cath, or any other modality. Cardiac arrhythmias refers to any change from the normal sequence of the electrical impulse. So this is our electrical path. That electrical impulse may happen too fast, too slow, or erratic. The heart doesn't beat properly. It can't pump blood effectively. When the heart doesn't pump blood effectively, the lungs, brain, and all the other organs can't work properly and may shut down or be damaged. So that electrical impulse is crucial. Some type, atrial fib, this is when the upper heart chambers contract irregularly. So we'll see an irregular pattern. Bradycardia is a slow heart rate. Conduction disorder can just simply be the heart does not beat normally. And there are many, many diagnoses in that category. Premature contraction or PBC could be a early heartbeat. Tachycardia is a very fast heart rate. And ventricular fibrillation is a disorganized contraction of the lower chambers of the heart. All of these present differently on our EKG when we're recording that electrical impulse of the heart. Some of the causes could be that we talked about our natural pacemaker, the SA node, develops an abnormal rate or rhythm. That normal conduction pathway is interrupted. Another part of the heart may take over as a pacemaker. And varying symptoms may be intermittent, continuous, short-term, or long-term. So we may hear, you know, some patients say, I have palpitations, a skipped beat occasionally. So it could be a short-term or it could be a long-term. Also, you can go in rhythm or out of rhythm if you have conditions such as atrial fibrillation. It can be chronic. What are some of the common coding scenarios for arrhythmias? Several diagnostic tests to diagnose and monitor. You'll hear about a Holter or a 24-hour monitor. An event monitor, which is a longer monitor that the patient may wear for up to 30 days. A tilt table test, a stress test, or an echocardiogram as well. Invasive procedure options. Generally, our electrophysiologists, EP services, do perform EP studies and ablations, which treat those certain arrhythmias. They include multiple add-on codes for these procedures and are very specific based on mapping, medication testing, and different pacing modalities with these EP study and ablations. Implantable devices, based on the type of arrhythmia, they could get an implantable defibrillator, which that's our ICD or AICD. A pacemaker is also another implantable device. We have loop recorders. We have other devices within this category. Most or the majority of these implantable devices do have the CMS Medicare National Coverage Determinations, which identify the medical necessity diagnosis and procedure codes that are used within that National Coverage Determination policy. Peripheral artery disease. So, we talk about PAD, but it's often referred to as peripheral vascular disease, PVD. PAD is the narrowing of the peripheral arteries that service the legs, stomach, arms, or head. Peripheral, in this case, means away from the heart in the outer regions of the body. PAD mostly affects the arteries in the legs most commonly. PAD and CAD are caused by atherosclerosis, which narrows and blocks arteries in critical regions of the body. The common symptoms, for example, that involve the lower extremities are cramping, pain, and tiredness in the leg or hip muscles while walking or climbing stairs. The pain goes away with rest but returns with walking again. This is when we talk about claudication from a coding perspective. Added risk of PAD are age, hypertension, high cholesterol, smoking, and diabetes, very similar to the other risk factors of cardiovascular diseases. The common coding, I will tell you, this is the most complex section of the ICD-10 diagnosis coding. It's about, if printed out, over 17 pages long in very, very small print, and it includes the types, locations, associated signs and symptoms that are involved with that PAD to be able to code to the level of specificity. Diagnostic testing that's often performed are ABI, ankyl-brachial indexes, Doppler, ultrasound imaging, CAT scans, MRAs, or angiography that's performed in our peripheral and coronary cath labs. Invasive procedures is really that revascularization of those veins and arteries. So these are endovascular procedures that can be done percutaneously, and then we also have surgical interventions, which may be open. So several different procedures in this area. Often need a goal-oriented comprehensive treatment program that includes medicine, exercise, and lifestyle modifications to improve the function and protect against other ischemic events. Smoking is critical in this area, so physicians will often have the patient going through some smoking cessation training and being able to have those underlying conditions, risk factors, et cetera, managed. Some key takeaways. There are several resources available from society, such as the American College of Cardiology, the American Medical Association, and the Heart Rhythm Society that actually even offers videos of the conduction of the heart. Our coding organizations, AAPC and AHIMA, also offer coursework that is deeper into the anatomy, physiology, and medical terminology. In cardiovascular, it's important to develop a relationship with the provider to answer these key questions. Try to view a procedure. This adds tons of value to your knowledge to know exactly how these procedures are performed, what it looks like, what's the reporting structure, and all of that content that the physician is seeing at the time of the procedure. Most importantly, staying as up-to-date as possible with technology and medical advancements is key. By joining the MedAxiom listservs and being a part of the MedAxiom network, we do provide key information timely on these advancements as they come out. We do have available some references and resources that you can look at that provides more detailed information for cardiovascular conditions and also video content to show different topics. If you have any questions, please reach out to us at RevenueCycleSolutions at MedAxiom.com. Thank you.

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