Hi, everyone, we're going to let people log in for a couple more minutes, but we will get started here shortly. Hello again, if you're just logging in, we will wait about another minute and then we will get started. Hello again everyone if you're just joining. We'll give it here about another 10-15 seconds and then Michelle you can you can take it away. Okay. Okay well hello everyone and welcome to Cardiothoracic Series 1. Jolene and I will be covering heart and bowel procedures today. To access the slide for today's presentation you need to click the chat chat box to access the link. Please don't use the chat box for anything else especially questions. Questions will be submitted through the Q&A box. As always we ask that you keep your questions on topic. We will answer as many questions as we can during the webcast but we'll also compile them and provide the answers in the academy dashboard on our website. The coding CEUs for AAPC will be available to view and download in the transcription section of your MedAxium Academy account. Our team will get your certificate uploaded to your account within one to two business days. Please note you do have to launch the webinar in order to obtain your CEU certificate. This is a screenshot of how you would download your CEU certificate from your MedAxium Academy account. Once you log in you will click on the presentation and then click claim CEUs. Then it will give you a PDF file that you can print or download to your computer. So on our agenda today we will cover coronary artery bypass grafts, open valve procedures, maze procedures, and other heart procedures. So we're going to start with my personal favorite coronary artery bypass grafts. Let's start by looking at the locations of the coronary arteries. The right coronary artery and the left main coronary artery both come off the root of the aorta. The RCA then descends down into small branches including the right posterior descending artery and acute marginal artery. The RCA supplies blood primarily to the right atrium, right ventricle, the SA node, and the AV node. The LAD and the circumflex split off the left main artery. Combine these two arteries supply blood to the left atrium and left ventricle. The circumflex artery is responsible for supplying blood to the left atrium and the posterior lateral aspect of the left ventricle, while the LAD supplies blood to the anterior portion of the left ventricle. Branches of these coronary arteries are the obtuse marginal arteries, the diagonals, and the septal perforators. The left ventricle the diagonals and the septal perforators. Here we show a breakdown of each artery with their branches. Next slide. A CABG can be done using only veins, meaning no arteries are used as grafts. With vein only cases, you would choose one of these codes which are split out by how many veins. In order to code these properly, you need to count the distal anastomosis. So for example, a one vein bypass would use code 33510. A two vein bypass would be 33511. Notice 33516 is six or more veins, so say an eight vein bypass was done, then you would still only code 33516 for six or more veins. Next slide. If the surgeon's only performing an arterial bypass, you would choose one of the codes from 33533 through 33536, depending on how many arterial grafts are used. Again, you count the distal anastomosis of these grafts. Now, if the surgeon is performing a combination CABG using both arterial and venous grafts, then you would choose two codes. One code from 33533 and one code from the artery section listed here on the top, and one code from the venous section 33517 through 33523 listed below. Again, you code by the distal anastomosis for how many arterial grafts and how many venous grafts are used. Here we have a couple of pictures of bypass grafts. The picture on the left shows a four-vessel bypass graft. To determine the correct amount of grafts and what codes to be used, you need to know what type of graft and where they are distally sewn. So here on the left, we can see that the lima artery was used and three staphenous vein grafts. The left internal mammary artery was sewn to the left anterior descending artery, and three staphenous vein grafts were sewn to the circumflex, the diagonal branch of the LAD, and the right coronary artery. In the picture on the right, we have the right internal thoracic artery sewn to the right posterior descending artery. Then we have a graft that is connected to the LAD and a branch of the LAD. This is a Y graft, and each anastomosis is counted. So even though there are only two actual grafts, they are distally sewn to three different places, therefore making this a three-vessel bypass. Next slide. Here we have the vessels that are commonly used for bypass grafts. Procurement of these are usually included in the graft code. However, the radial artery is used here, or there is a code, sorry, for removing that vessel, and we'll go over that in a future slide. So in the top picture, they are removing the radial artery in the arm to be used as a bypass, which is then shown being used in the bottom picture. Next slide. The staphenous vein is the most common vessel used in cabbages. Please do not ever use the ligation codes 37700 through 37735 for removal of this vein. Next slide. Here are some things to remember with grafting. When only a vein bypass is done, procurement of the staphenous vein is included in the work for codes 33510 through 33516. Procurement of the lima and rima is included in the work for codes 33533 through 33536. To report endoscopic vein harvesting of a, or endoscopic harvesting of a vein, you would code 33508. 33509 would be used for endoscopic harvest of an upper extremity artery. Keep in mind that 33508 and 33509 bundle with the arterial graft codes 33533 and 33536, but a 59 or X modifier is allowed on the endoscopic codes. 35572 is reported for harvesting of a femoral popliteal vein. For open harvest of an upper extremity vein, code 35500, and for open harvesting of an upper extremity artery, 35600 would be used. The use of code 33530 is for the reoperation of either a valve procedure or a cabbage. For example, if the patient had a prior valve procedure at least 30 days prior to a cabbage, you would use this code, or vice versa. It's also used for a prior valve or a current valve procedure, a prior cabbage, or a current cabbage. Note that this code is also used with bental procedure. Also, if the patient had a prior sternotomy and is now having a cabbage or a valve, you can use this code as well. These codes describe the surgical exclusion of the left atrial appendage. These procedures are performed in patients with atrial fibrillation. The LAA is the most common site for thrombus. Blood collects in the LAA, where clots can form and travel outside the heart to the brain, resulting in a stroke. LAA can be performed as a standalone procedure reported with code 33267 via sternotomy or thoracotomy. 33267 would not be coded in conjunction with other sternotomy or thoracotomy procedures performed during the same session. 33268 is an add-on code to be used at the time of another sternotomy or thoracotomy procedure. If done thoroscopic, use code 33269. Keep in mind that all three of these codes should not be reported with the mitral valve repair or replacement procedure or any maze procedures. If the surgeon performs an endarterectomy of the left anterior descending or the left circumflex or the right coronary artery, you use this code. If they perform an endarterectomy on all three arteries, then you can list this code three times. It can be reported for each artery. There is no code for an endarterectomy of the aorta, so if the surgeon performs that, it is reported for each artery. There is no code for an endarterectomy of the aorta, so if the surgeon performs that, it is reported with the unlisted code 33999. I also wanted to point out a couple of procedures that are almost always performed with a CABG. 33542 myocardial resection and 33545 repair of post-infarct ventricular septal defect. This procedure is to treat congestive heart failure subsequent to a myocardial infarction that has caused scarring or aneurysm of the left ventricle, resulting in an enlarged, rounded heart. SVR restores the heart to a normal size and shape, thereby improving function. Cardiopulmonary bypass is initiated. The ventricle is collapsed. A small incision is made in the bottom of the left ventricle through the scar tissue. The heart is opened, and the area between the scar and the good heart muscle is identified. Using a plastic model of the heart selected based on the body surface of the patient, the surgeon reshapes the heart. Rather than closing the defect, the surgeon sutures a patch over the defect to restore the normal spherical shape of the heart. This is a new code for this year for the use of the epiaortic ultrasound. The surgeon must document the findings of the aorta and that a permanent record of the image was saved in order to build this code. It's not to be used for harvesting of the graphs or used as a mapping tool. It's only billed when it's used to aid cannulation for cardiopulmonary bypass, a cross-clamp evaluation, or to identify a dissection of the aorta. So now we'll go over some case examples. So here's my case number one. We have our diagnosis and our wish list. The indications are this is a 76-year-old man with multiple cardiac risk factors who was transferred to our hospital after the finding of severe three-vessel coronary artery disease on a cardiac catheterization done for progressive dyspnea and congestive heart failure symptoms. He underwent a left carotid endarterectomy by vascular surgery three days prior and was stable, therefore consented for urgent coronary artery bypass grafting. Next slide. After appropriate informed consent was obtained, the patient was brought to the operating room where he was placed in position on the operating table. He was intubated and placed under general endotracheal anesthesia. Following sterile prep and drape, a media sternotomy was performed. The left internal mammary artery was harvested from the left chest wall in a semi-skeletonized fashion. Greater staphinous vein was harvested endoscopically from the patient's left lower extremity. Following conduit harvest, the pericardium was opened. The ascending aorta was palpitated and noted to be soft and free of calcified plaque. The aortic arch had some moderate calcification. Following heparinization, the patient was cannulated via the ascending aorta and right atrium. He was started on cardiopulmonary bypass and the temperature allowed to drift. Following an excellent diastolic arrest, attention was first turned towards the OM. The OM was a large vessel in the 2.5 through 3 millimeter range. The first piece of vein was anastomosed here using a running proline suture in decide fashion. Additional cardiopulosia was given down the graft and attention then turned towards the terminal circumflex. This was sharply opened. It was likewise large vessel about two millimeters and the second piece of vein was anastomosed here using running proline suture in an endoside fashion. Additional cardiopulosia was given down the graft and attention was then turned towards the PDA. The PDA was open. This was a similar vessel about 1.5 millimeter in size and the third piece of vein was anastomosed here using running proline suture in decide fashion. Then attention was turned towards the LAD. The lima was trimmed to length and the LAD was open to its mid distal portion and the lima LAD anastomosis constructed using a running proline suture in decide fashion. Then during the same cross clamp session all proximal vein grafts anastomosis were constructed separately onto the ascending aorta using punch aortotomy and running proline suture. They were marked with graft markers. This slide has his operative findings. Our final answers for this case are 33533 for one arterial bypass graft, 33519 for three venous bypass grafts, and 33508 with a 59 or x modifier depending on your carrier for the endoscopic vein harvest. Here's case number two. So we have our diagnoses and our wish list. The patient is a 58 year old who presents with findings of multi-vessel coronary artery disease, AFib, and angina. The patient was brought to the operating room. Patient was prepped, positioned, and draped in the usual fashion. Next careful medial sternotomy was performed. The left internal mammary artery was harvested from the posterior chest wall. Endoscopic vein was taken from the lower extremity on the left side utilizing the endoscopic harvesting system. Full cardiopulmonary bypass was initiated. Aortic cross clamp was gently applied. Cold antigrade blood cardiopulmonary was given down the route for a rest dose of 900 ml. First graft was the high diagonal ramus type vessel grafted in a side-to-side fashion with running proline. The second vein graft was then grafted to the mid-obtuse marginal. After completing these two distal touchdowns, the patient was brought to the operating room. We grafted the PDA with running proline. This vein was brought around the acute marginal of the heart, anastomosed to the anterolateral wall of the aorta. Finally, the lemur was anastomosed to the LAD with a nice target in the midpoint and running proline. The aortic route was carefully de-aired and the patient was easily weaned from cardiopulmonary bypass. Given that the patient had intermittent atrial fibrillation, the left atrial appendage was ligated with a clip which was placed at the base and confirmed on TEE. TEE images obtained, the probe was placed by the anesthesiologist, documented overall reasonable ventricular function, and then he said, I personally reviewed and independently interpreted the TEE findings. So for our final answers on this case, we have 33533 for one arterial bypass graft, 33519 for three venous bypass grafts, 3350859 or an X modifier for the endoscopic vein harvest, 33268 for the LAA ligation, and then 9331426 for the TEE. Okay, so for my third and final case, we have our diagnosis and our wish list here, and our indications are a 55-year-old male presenting with complicated multivessel coronary artery disease and unstable angina. The patient was consented for the procedure after his history and physical exam reviewed and his radiological imaging confirmed adequacy of left radial artery conduit. He was taken to the operating room for placement of lines per protocol. Midline sternotomy was performed. Endoscopic vein harvest from the right lower extremity and endoscopic radial artery harvest from the left upper extremity was performed. Pericardium was opened in reverse TEE fashion. We commenced cardiopulmonary bypass and elevated target distal targets. Cross clamp was applied. The left atrial appendage was dissected at the base and the left atrial appendage clip was placed. First, I evaluated both the obtuse marginals. First was a reasonable target. The second was a small 1.25 millimeter vessel. Both were dissected open lengthwise. Right atrial or right radial artery was open in its mid portion and appropriate location with proline suture used to create a side-to-side anastomosis for the first obtuse marginal in a diamond shape configuration. Next, I completed an endoside anastomosis with the radial and obtuse marginal number two, again using proline suture. Complete distal flow was confirmed using cardiopulmonary solution of blood. Radial was measured and had an adequate link to reach the aorta. A small punch was used on the aorta. A proline suture was used to create a proximal anastomosis which was marked with graft marker. Next, I evaluated the inferior wall. Posterior descending artery had a distal lesion and it was dissected and the lesion was transected as a long patch was performed over one centimeter of this large lesion which was also served as our distal anastomosis. Staph in the spain was then sewn endoside to the PDA. Distal flow was confirmed using cardiopulmonary solution of blood. Vein was measured and oriented to the ascending aorta and a single proximal aortotomy was created and proximal anastomosis was fashioned using proline suture. This was marked with a graft marker. Next, I evaluated the anterior wall. Diagonal artery and left anterior descending artery were in appropriate locations for sequence. Both were dissected open lengthwise. Diagonal was a 1.75 millimeter vessel. The left descending artery, the left anterior descending artery was a one to two millimeter vessel. The left internal mammary was opened in mid portion and proline suture was used to create a side-to-side anastomosis with the diagonal and an end-to-side anastomosis was then fashioned to the left internal mammary artery and the left anterior descending artery. So our final answers for this case was 33536 for four arterial bypass grafts, 33517 for one venous graft, 3350859 or X-modifier for the endoscopic vein harvest, and 3350959 or X-modifier for the endoscopic radial vein harvest. Also note that I didn't code the LAA in this case because it didn't meet medical necessity. So okay, I will now turn this over to Jolene. Thank you Michelle, great job. So now I'm going to talk about heart valves and then we'll, I'll also get into other procedures. Note I am not covering tavers or timbers or anything to do with structural heart. That would be a separate webcast and not included in this. So for some of you, this is probably going to be a refresher, but I do like to go through the anatomy of the blood flow in the heart so that some of our newer coders, you know, it helps them out a lot. So as we all know, your veins are blue because they don't have a lot of oxygen and they're oxygen deprived. They're not completely without oxygen, but they don't have as much. And then your arteries are red because they're oxygen rich. So as the blood comes up through the inferior vena cava, and then it comes into the SVC and it's not showing on here real well, but anyway, the blood comes through there and then comes into the right atrium. And then what happens is on that valve contracts and it, well, the atrium contracts and pushes the blood through the tricuspid valve and it goes down into the right ventricle. Then the ventricle contracts and pushes the blood out through the pulmonary valve into the pulmonary arteries. And this is going to go out, this is your pulmonary valve, and then this is going to go out to the lungs, both the right and the left. This pulmonary artery runs underneath the aorta, but it goes out to the lungs, gets oxygenated, and then it comes back through the pulmonary veins and dumps into the left atrium. Well, then once that happens, the left atrium contracts, pushes the blood through the mitral valve down into the left ventricle. It contracts, pushes the blood through the aortic valve out to the aorta, out to the rest of the body. So that, you know, that helps figure out what's going on with all of this. And as you can see, if there's any disruption in any of this flow, it's going to cause problems with your heart. My clicker's slow today. Okay. So again, we've got the aortic valve and it's, um, it's right here. And then we have the tricuspid, there, tricuspid valves down here. And then the pulmonary valve again is up here. And then finally the mitral valve. So, um, do note that a lot of the pulmonary valve problems do end up being more congenital than adult, but sometimes there is reason for, um, an adult CT surgeon to perform pulmonary valve procedures, but it's not as often and that's more falls under the congenital. So again, so our function of the aortic valve, it lies in between the aorta and the left ventricle. And again, that ventricle will push the blood, um, through that valve up into the aorta, which then goes out to the body. So this, this picture here shows you that, you know, when, when it's healthy, um, first off, uh, tricuspid is a normal valve. If you, and that means there's, there's three leaflets. If you ever see bicuspid, that's actually, um, a congenital problem, but doesn't necessarily relate into, um, significant problems. It can, but, and you know, some of that is kind of common to have a, for people to have a bicuspid valve. But when that happens, it means they only have two leaflets versus a three, but so this is showing the valve open. And then this picture here shows that it's closed and it's closed properly. Now, uh, we'll talk about a little bit more of what happens on the, uh, next slide. So when the valve, um, narrows, that's when you have stenosis and, um, you can see here, you know, there's like buildup and it's just not, um, it's not nice and healthy and open like this one. And then when it closes, it doesn't always close properly. And this reduces the amount of blood that goes into the aorta, which this, you know, in turn causes the heart to work harder. And it does limit the amount of, um, blood that's pumped, sorry, I need a new mouth. All right. So when we're talking about regurgitation or insufficiency, that happens when valves do not close properly and they allow blood to leak back. So, you know, if you think about, you know, for the first slide, when I started talking about anatomy, so when there's a ventricle contracts, it's supposed to push the blood this way. Well, if, if there's regurgitation, it won't close properly and then blood leaks back into the ventricle. So again, we're not allowing the full amount of blood to get out to the body. And so next we're going to talk about the mitral valve and again, it is, you know, its function is to, um, uh, it is actually known as the bicuspid valve, by the way, um, another term for that. It does again lie between the left atrium, left ventricle, and it regulates the blood from the atrium into that left ventricle on the left side of the heart. So again, this shows a better picture of regurgitation than my aortic valve one did, but as you can see here, um, you know, when that valve doesn't close properly, it pushes that blood keeps going back up into, um, the atrium instead of all sitting down here nicely in the ventricle. And so again, that, um, causes, uh, the heart to work harder. Any of these things that, you know, like I said in the beginning, if they don't function properly, then it causes all kinds of problems. And again, stenosis is a narrowing of that valve, um, opening. Now note on the mitral, mitral stenosis is mainly caused by rheumatic fever. So if you, if you think about that, and I know there's this whole, and I'm not, Jamie is the ICD-10 expert. She talks about that in September, but I do want to point out when it comes to rheumatic fever, it is rare for us citizens to have it because it, um, rheumatic fever actually is a result from strep throat, scarlet fever, that's gone untreated well now, um, you know, we do obviously have some instances when, you know, people move here from other countries that maybe didn't have, um, the healthcare that we have. And um, so now, you know, you will run across people that have had rheumatic fever, but um, it is rare for most citizens of the United States because our, you know, our healthcare is more developed, and um, you know, we usually treat all of those things. So next I want to talk about the tricuspid valve. It is also known as the right atrium ventricular valve. Again, it's portioned at the superior portion of the right ventricle, and again, it prevents that blood from flowing back into the right atrium. And basically, as we talked about before, I mean, you know, regurgitation is, it's the same no matter what valve we're talking about. It's that blood's leaking back through that valve instead of going through the flow it's supposed to. Um, interestingly enough, a lot of people don't even know they have tricuspid regurgitation. Um, but there are some symptoms that, um, uh, can alert you to that. And some of that is, uh, you can see the pulses in the vein in your neck, shortness of breath with the activity or when you lie down, that can be a result of tricuspid regurg, enlarged livers, um, swelling in the abdomen, in your legs, feet, or ankles. Now, um, just because people have that doesn't automatically mean they have tricuspid regurgitation, especially with the legs. Um, it could be, you know, venous insufficiency, it could be, um, congestive heart failure, that type of thing. But just, you know, keep in mind that that is some of the symptoms of a tricuspid problem. And again, then finally, the pulmonary valve allows the blood to pass from the right ventricle into the pulmonary artery, and again, out to the lungs to receive, um, oxygenation. And stenosis is when that valve narrows, and, um, the heart can enlarge due to this condition, and it also can increase hypertension to the right side of the heart. And as always, regurgitation allows that blood to, um, flow back in. As that starts to increase, then, you know, something has to be done about any of that regurgitation. It does require medical attention. It's not going to go away on its own. All right, so now I'm going to kind of break down some of the procedures. Now, these are typical valves that are actually replaced. You'll see St. Jude, Porcine are common. It doesn't really matter what type of valve, as long as, um, and we'll get into this when I get into the specific codes, because some of them are a little bit different, but they're not often used. All right. All right, so sometimes, um, surgeons can do valvoplasty versus actually replacing the valve, and basically what breaks out these two codes is whether or not the repair is simple or whether or not it's complex. Um, again, it's important for your surgeons to document clearly, um, if it is complex, because you're, you know, otherwise you're not going to know, and you could pick the wrong code. So, for 33404, this procedure, um, this procedure is a construction of the apical aortic conduit. It can be, this can be done. I haven't seen it done a lot, um, but it is. And then 33405 is probably our most common, and it's, uh, it is done with cardiopulmonary bypass, and note it's a prosthetic valve, and it's other than a homographed or a stentless valve. So, sometimes you'll see your surgeons document, um, they might document words such as, um, a stented valve, um, if they don't say, you know, the, uh, sometimes they'll just say the stented valve. They're not going to, um, they won't always word in their OR report exactly how it reads in the CPT book, so keep that in mind. Uh, 33406 is an allograft, and basically how this is done is, um, and I haven't seen this in years, but, um, basically the surgeon actually creates the valve in the OR, and they, um, they use, uh, pig, um, pig tissue, and they kind of create their own little, it's an allograft is what they call it, and it's created freehand, um, so you don't see them too much anymore. And then, um, in 33410, this again is a, um, stentless tissue valve, so again 33405 is actually stented, and 33410 is stentless, so pay attention if this is how your providers document, um, because that will help you in picking the right coat. For, um, 334, 33440, this is actually a Ross-Kono procedure, and it's a combo. There are still individual for the Ross and an individual code for the Kono procedure, but, um, if you're performing both, this is the code that is used, and this is where they replace the aortic valve, and then also enlarge the aortic annulus. This procedure is not to replace, I'm sorry, it's, um, um, not only to replace the aortic valve, but it also widens that ventricular septum. It is done for treatment of aortic stenosis and ventricular outflow tract stenosis. Note that this code is out of sequence of the others. When you look in the CPT book, and it is also not reportable with any other aortic valve replacement, um, or the pulmonary valve replacement codes and the pulmonary atresia with ventricular septal defect code as well. Don't report any of that separate. Okay, 33411, um, sometimes you'll see this called the NICS procedure. This is where, uh, they replace the valve and then also enlarge those aortic annulus. Um, they have, uh, the Kono procedure is for transventricular aortic canal, and geez, the Kono procedure is for transventricular aortic annulus enlargement, and that is with the 33412. The Ross procedure is complicated, and that's where they use the pulmonary artery and attach it to the aortic position after the valve is removed. So they actually directly put that pulmonary, um, graft, uh, pulmonary artery, they attach it to where the aortic valve would go. 33414 is when they, um, treat the left ventricular outflow track by a patch enlargement, and that's performed when there's an obstruction in the ventricular outflow track. The aortic valve is replaced, and then the, uh, left ventricular outflow track is reconstruction, reconstructed with a patch. Uh, you can also code 33415 for subvalvular aortic stenosis, and also a ventricular myotomy can also be, be performed as well as aortoplasty using a gusset. So note, when it comes to the aortic reconstruction, that is not an annulus enlargement, so don't think you should code the 33411 with that. There is no separate code for the aortic, uh, root construction. I'm not talking about a bental here, that's a different, that's a different ballgame. That's when you're, um, the bental or the david is when you also involve the, um, ascending aorta, and this isn't the case. This would just be, you know, they, they replace the aortic valve and they make the root bigger. There is no, uh, specific code for that. The, uh, Society of Thoracic Surgeons does recommend that we build the unlisted code in that case. Um, some, some schools of thought are also to add a 22 modifier. Um, that would be if, uh, you know, if you, if you don't have a lot of luck with the unlisted, you can try the 22, that type of thing. Also note, we can do a sinus ovale salvo, aneurysm repair, and then, um, also the exclusion of the left atrial appendage. Um, I want to talk one more thing about that left atrial appendage. So in the CPT book, it states that it's for, uh, atrial fib or an arrhythmia. It can, it can be just an arrhythmia. It doesn't necessarily have to be atrial fib. However, you cannot code this, um, for prevention. The CPT book talks about prevention or mitigation of, um, arthritis, and Medicare will not allow you to code the LAA for, um, for prevention. So keep that in mind. A lot of times the surgeons will do it and the patient doesn't have, um, atrial fib. So don't automatically code it just because it's there, just because they've done it. All right. So now let's talk about the mitral valve and the tricuspid valve procedures. So with mitral, uh, the most common, again, would be repair or replacement. Keep in mind if they attempt to repair and then they have to convert to a replacement, and this goes with, with anything. You have to code the most extensive procedure. You cannot code both. However, if you're, uh, if you're lucky enough that your carriers will reimburse the 22 modifier, and if you're lucky enough that your surgeons, uh, give you a nice little, we do recommend a separate paragraph just to, um, point out what was more difficult, what happened, the extra time, all of that type of thing. So if you're lucky enough, if your carriers are pretty good about reimbursing you with the 22, you could do the 22, but once, once it's gone from a repair to a replacement, you only can code the replacement. So when we're coding mitral valve aplasty, the procedure 33420, they actually open the pericardium and make an incision within, uh, uh, the left atrial appendage. They, um, they can use a tub's dilator, or even the physician can use his finger and should have a glove on it. And that is introduced into the left ventricle by way of the apex, and it opens in the valve. Calcium deposits can be removed from the annulus and the leaflets with what's called a bone nibbler. And then upon completion of the, that valvotomy, the dilator or the surgeon's finger, they remove that and then close that with sutures. For 33422, the left atrium is open from the right side. The mitral valve is exposed, and then, um, they, uh, they work on the scar tissue between the lateral ends of the valve leaflet. They divide those sharply. When it comes to 33425, again, they go, uh, now on this side, they'll go through the left atrium, and then any redundant mitral valve tissue is excised. And then any defects, um, in the valve leaflets are also closed with sutures. For 33426, um, they will place a prosthetic ring. Um, and then 33427, so they may or may not, um, actually use a ring. They don't have to in 33427, but they do, um, uh, the difference between the two is there's also an extensive repair, which includes, like, transfer from, uh, of cords from the posterior leaflet, uh, to the anterior leaflet. And then finally, of course, um, we have our, our replacement, which is done with 33430. Again, um, with tricuspid valve, again, we can do, uh, valvectomies or valvoplasties. They also have with and without ring. And then also we, you know, we have the replacement. Um, if a patient has an Epstein anomaly and then tricuspid valve annulus is displaced onto the right ventricle and the valve leaflets become tethered to the wall of the ventricle, um, this will be done, but this was normally again going, um, it is a congenital condition, but it can be done by an adult surgeon and just, and what I mean by that is all of our surgeons, I hope, are adults. But the point being that whether or not the patient has a congenital condition that they were born with, or if it's acquired, you know, condition at that. But sometimes the Epstein anomaly won't necessarily cause any factors till the patient gets older I've just seen this question come in, can you not build a valve repair with a 52 modifier and then bill for the replacement? No, you cannot. Medicare only will allow, now if they try the repair and don't replace and they don't and that it fails and they stop the procedure, then yes, you can build a repair with a 52. But you only code the most extensive procedure that's done. You would not code for both. All right, so when we're billing for multiple valves or multiple heart procedures, such as a CABG and a valve, you always want to list the most extensive repair first. And then if your carrier requires you to apply the 51 modifier, then you need to do that. Keep in mind though, you always want the 51 to be on the lesser procedures. If you put it on, so let's say for example, we're doing a aortic valve and then a CABG. Well the valve is actually a more extensive procedure than the CABG. So therefore, you don't want to put the 51 on the valve, you want to put the 51 on the CABG code. And then also keep in mind, not all carriers require the 51. So if yours does not, do not add them, because then they're going to reduce it twice. Because a lot of a lot of the carriers will automatically do their reductions. That's why they don't want you to put the 51. But I know there are carriers out there in different parts of the country that you have to add the 51. So again, you need to do what you have been doing. So don't change anything, just say, oh, well, Jolene said that we have to put a 51. No, you don't. So only if your carrier wants you to. And then also note with the 33530, which Michelle had covered very well during the CABG, it's also used with valves. But note again, so this is kind of new, it's probably been two, possibly three years. They're actually allowing, so if, I don't know, let's say a patient had an ascending aortic repair, but they've gone through the sternum before, and now they're coming in for either a valve procedure or CABG, and they have to reopen that sternotomy. As long as your next operation is a valve or a CABG, you can build a redo. So keep that in mind, because that's kind of new, because it used to be you had to either be redoing a CABG or a valve. But now it's if they had a previous sternotomy, you can use that. But don't use it. Okay, now let me back up here. Don't use it if they've had a CABG and now they're going through to replace that ascending aorta, unless they're doing a valve with that ascending aorta, something like that. So I'm going to briefly talk about the pulmonary artery again. We don't do a lot with that. So we have valvotomy, which is a closed heart via the pulmonary artery. And then we have 33474, which is open heart and cardiopulmonary bypass, 75 is for a replacement of the valve. And then we have 33476, which is right ventricular resection for infundibular stenosis. And that's with or without commiserotomy. And then in 33478, that's for that outflow tract augmentation that's done with a gusset again or with or without commiserotomy or infundibular resection. So let's move on to maize. So maize procedures are very interesting. And of course, they're not as done as often as they used to be because of the adventation of the EP providers actually doing atrial fib ablations. This is done to treat atrial fibulation. It's a combination of surgical incisions and or energy sources. Lesions are actually created to disrupt conduction to remove the atrial fib. So the biggest difference between the two is this is going through an open chest. So they're actually cutting the chest open with these, with this group anyway. And then again, they create those lesions that will disrupt conduction to remove the atrial fib. They are, they can be done alone, or they can be done in conjunction with heart procedures. Normally I would say that they're done by themselves now, especially with, because of EP. Now there's, there's some cases where they will, but normally what'll happen is a patient has something else going on and the surgeon's going to be in there anyway. So then they'll go ahead and do that maize. Also keep in mind, I like to point this out, even though we have the code for the LAA, which is the left atrial appendage, that alone is not enough to be considered a maize. And again, if they perform a maize, you do not code that LAA separately at all. You don't code it with the maize and you don't code it with the mitral valve. All right. So this is kind of, oh, these can be endoscopically done too. They don't have to be open, but endoscopic, you know, when you have an endoscopic procedure, they create the little holes and run the scope into the hole in your chest and that. But there, I don't see a lot of them done either. So again, they're still hanging out there for just in case. But our codes are also split up as to whether or not they're open, limited, open off a bypass, or open on bypass, maize open, limited, that's done with another heart procedure, open off bypass, and then open on bypass. So what this means is, so 3-3-2-5-5, 3-3-2-5-6, 3-3-2-5-8, and 3-3-2-5-9 are actually extensive. They're extensive maizes. The limited ones are the 3-3-2-5-4, but don't, you know, I know when these kind of first came out, and this has been, gosh, I don't know, almost 20 years ago, probably, a lot of people would get this confused as to whether or not, you know, if they didn't put them on by, or if they put them on bypass, it's automatically the 3-3-2-5-6 or the 3-3-2-5-9. That's not the case. They could be on bypass, but still only be a limited maize. So don't leave, kind of leave the bypass out of it, unless, of course, it's extensive and they're not on bypass. That's the only time you got to worry about that. Again, the codes are divided by whether or not it's limited or extensive. And then finally, if you think about what makes it extensive, is it includes everything that's done in the limited maize, but then there's additional ablation that involves the atrial ventricular annulus, and usually your physicians should tell you if they're doing extensive. If you're ever unsure, be sure you go back and talk with your provider and, you know, have that communication with them and let them know, I don't know what you're doing. I don't, you know, I don't know if you're doing extensive. I don't know if you're doing limited. If it's hard to tell from the, you know, oops, wow, that got away from me quickly. If it's hard to tell from the dictation, then you definitely need to talk to your surgeons about that. Okay. So some other heart procedures. So we have procedures of the pericardium. We can do pericardiocentesis. That doesn't necessarily have to be done by a surgeon, cardiologists do them as well. Then we have in 33017-018, we have drainage with an indwelling catheter that does include fluoroscopy and or ultrasound when performed. 33017 is for six and older without a congenital anomaly and 33018 is a birth through five years or it doesn't matter your age if, if you do have a congenital anomaly. In 33019, we have pericardial drainage with insertion of that indwelling cath and that includes CT guidance 33020 is pericotomy if they do a removal of clot or form body. And then we can also do creation of pericardial window. Or sometimes you'll see it listed as, you know, they some are very good at saying they did a pericardial window and then sometimes they'll just say that they did a resection for drainage. They can also do that thoroscopically with VAT. So keep that in mind, that's the VATs code I've added there. And then in 33030 and 031, we have that pericardiectomy, which is subtotal or complete. And the first code is without cardiopulmonary bypass and the second code is with. And then in 33050, we have resection of that pericardial sister tumor. So these are some of the things you, you can possibly run into. Sometimes they're done in conjunction with other procedures and sometimes they are standalone. All right. So next we're going to talk a little bit about neoplasms and TMR, not to be confused with TMI. TMR is actually transmyocardial laser revascularization. So that's what that stands for. In 33120, we have where they excise an intracardiac tumor. So that means that tumors within the heart itself. So it's in one of the chambers, you know, something to that effect. For 33130, it's external. So it's on the outside of the heart. It's not inside the heart. And again, then TMR is, that is done by thoracotomy. It is a separate procedure. So for 33140, that has to be done by itself or with something that's not related. If they happen to do another cardiac procedure, then you use the add-on code, which is the 33141. All right. So next I want to talk about some procedures for the heart and great vessels. Now this is always a source of contention because of the fact these are for trauma. They're not for surgically created wounds. So these are people that, um, yeah, gunshots, their stabbings, maybe they got in a car accident. There's some type of trauma. This is not a surgical trauma. And then, um, when it comes to the first set of codes here, the 33300 and the 05, these are direct repairs of the cardiac wound. For 10 and 15, this is removal of form body or an atrial or ventricular thrombus. And then, um, as far as this set here, these are not congenital diseases. This is something that's acquired. And then with 33320 and 22, that suture repair of the aorta or great vessels, um, again, not a congenital, um, disease, this is for acquired. And then, um, they're, they're split out between cardiopulmonary bypass and without, without and with. And then finally we have, um, insertion of, um, a shunt or graft, um, or I'm sorry, insertion of a graft for great vessels without a shunt or cardiopulmonary bypass. And then 33335 is with bypass. Again, you're, you're talking about some type of trauma. If something else happens, um, I'm just seeing a question come in. So what would you code for a tear during a procedure that the surgeon was called in to repair? Uh, so during a cath with cardiology and calls in the surgeon to fix, um, that could probably be argued because the surgeon didn't create it. So I, my best suggestion is to check with your carrier. They may want you to do unlisted, um, but you definitely are not going to use this. So if you're a surgeon while he's doing a cabbage punctures the heart, he cannot then turn around and, and bill for repairing it because he caused it. So, um, or if, you know, something happens later that is from a surgically created wound that they performed, then I wouldn't do it. But it's always best to check with your, um, uh, your carriers on this, but the description does specifically state not for surgically created wounds. So me personally, um, whenever, uh, we ran into this, when I was at a practice, we would code the unlisted code or an appropriate, a different repair, not, not these. Okay. So septal defects, again, these are not necessarily, um, the few that I'm going to cover, um, these are, um, and what I mean by non-congenital CT surgeons on that slide, not to, not to confuse you. I'm not saying that it's a non-congenital condition. I'm saying it doesn't have to be basically a pediatric CT surgeon, um, a regular CT surgeon can perform these and they often do, especially again, if they're, you know, doing a valve procedure or, um, um, a CABG, sometimes, um, there are defects, um, that aren't necessarily congenital only, but, um, excuse me, but keep in mind that, um, and again, I'm not getting into congenital CT surgery here. I'm just covering a few things that you might see those of you that are billing for, uh, CT surgeons that, that perform adult procedures. So 33641 is often reported with other heart surgeries and it's normally done for the, uh, PFO closure. Um, you know, PFO again is that Patent Form on Oboli and it's something that, um, people are born with. Sometimes they don't even know they had it until they've developed some other, uh, condition. It can be small enough, um, that they don't even know and then, you know, it's because it didn't close properly as they grew, but a lot of people don't even know they have it. So, um, my, uh, uh, father-in-law had no idea that he had one and they started, they were actually, uh, they were doing a cabbage and then they found it. So anyway, so for 33647, that's repair of atrial and ventricular septal defects. And that's done with a direct patch or direct closure or a patch closure. And then we also have, um, uh, the 33681, which is closure of a single ventricular septal defect. Now, oftentimes this one, um, is done when, um, a patient has ischemia and there's dead heart muscles. So they'll go in and, uh, the surgeons will go in and fix that. So that one is specifically not congenital. It can be, but when the, when our adult, um, uh, CT surgeons are doing this, then they're doing it for that ischemic and the, and there's dead heart muscle and, and, uh, they cut that away, right? So some other miscellaneous procedures, the 35820, I really want to stress. This is for post-op hemorrhaging, thrombosis, or infection. If anything else is done, you're going to have to find a different code. Now, sometimes there's a, I know there's a thoracotomy code, uh, for exploration. There's mediastinal codes, things like that. Do not code this though for, um, if they don't have an infection, hemorrhage, or thrombosis, don't use this code. If you are within a 90 day global, more than likely you will need to use a 78 modifier to indicate to re that you've returned to the OR. Now sometimes, um, if this happens bedside, which can often happen, as long as your surgeon documents in the note that they did not have time to take the person, uh, patient back to the OR and they went ahead and perform that, um, chest exploration and, and fix whatever was going on, especially if they're bleeding. I mean, usually if they're bleeding and it's, um, they're hemorrhaging enough, they're going to do it right then and there. The point is they have to document that they, there was no time to take that patient back to the OR. And as long as they do that, then you can build this code with a 78 modifier. For 21750, this can be a standalone procedure. Um, it can also be done, um, when you have a delayed sternal closure. If this is in the, um, uh, 90 day global, then you're going to need, um, you'll need a 58 with this. Keep in mind too, uh, because it's, it's planned. We don't leave people open when we cut them. I mean, we do, but medical reasons, they, they leave them open, but we have to close them. So you do, you can build this, but again, you have to put a modifier on it to indicate that, you know, this was planned, um, you know, when, when they leave the patients open also, and I've been running into this recently in audits and I don't know where, um, this information has come from, but please do not reduce any of your surgeries where they leave the patient open and come back to close them later. Because when you put that 52 modifier on there, that is an automatic 50% reduction of that procedure. Um, you don't want that because just leaving the sternum open is not, it's not a big deal. That's not enough to reduce that procedure by 50%. So, um, keep in mind that you don't have to do that. You just, when you bring them back, you either have to, more than likely you're going to use the 58 modifier, um, because more than likely it's going to be within 90 days that they're going to bring them back. Also note on this, uh, 21750, or no, I'm sorry, on the 21627, that sternal debridement, they actually have to debride the bone. It's not just the tissue. They have to actually, they have to do something with the bone. If they don't, if they don't debride the bone, then you cannot use this code. You'll have to look at like something in the 1000 code. Also note, um, for the TEE, now there's a couple of things when it comes to the TEE. Some surgeons will do their own interpretation and that's fine. It's perfectly proper to do that. That being said, they need to make sure they're the only ones doing that interpretation because if the anesthesiologist does it, or if the, um, uh, cardiologist does that interpretation, Medicare is not going to pay for too all. So then it usually boils down to is who got the, who got their codes in faster. But, um, that is, uh, a lot of surgeons do like to do their own interpretation. Also keep in mind, um, there is for the most part, most places have an LCD on this. If they do this and they do not have medical necessity, then they're probably not going to be paid. So, um, keep that in mind as well, but I'm not, um, I'm not telling surgeons that they can't do it, but it's just a matter of whether or not they'll actually get reimbursed because, you know, it, it does have its place to be done. But if there's, you know, if everything's normal, if there's nothing wrong with the valves and they don't have congestive heart failure, or any of those things that go along with, um. You're, uh, if there's an NCD or an LCD on it, then, you know, it, it's not going to pay because it has not met medical necessity. Again, the biggest thing, though, is they need to coordinate and they need to cut a deal and, you know, make sure that nobody else is going to code for it. And then also, you know. They have to append the 26 modifier, um, because this is. This would be done with a surgery that's normally inpatient. So, we're going to jump into some case examples. So, for, uh, excuse me, for my first case, we have a patient that has a severe mitral stenosis, history of rheumatic heart disease. I don't remember what group sent me this, but man, they're, uh. Their surgeon needs a great big pat on the back for being specific that it's rheumatic because I know all of us struggle with, with that patient also has chronic and diastolic or systolic and diastolic failure, severe pulmonary hypertension, proximal atrial fib, possible cirrhosis, and thrombocytopenia. So, our operation that's being performed is we have a mitral valve replacement. They're also performing a 2-vessel coronary artery bypass in situ with a skeletonized left internal mammary artery. And they're going to put that on the distal left anterior descending and then reverse saphenous vein to the ramus. And they're also telling me that they did endoscopic saphenous vein harvesting. They're also doing an extensive biatrial maze using radiofrequency ablation and cryoablation along with that ligation of that LAA. But keep in mind, there's 2 things on that. So, of course, this is the wish list. I'm not coding from this. They have to prove they're doing all this to me in the note. But no, because we have that LAA with a maze and with that mitral valve, we would not separately code for that. Even though the patient does have a fib, they're actually going to do a maze. So, and again, this provider documented that it was extensive, which again is always helpful. And I know I say this a lot, and I especially say it every time I do the CT surgery webcast, have these conversations with your surgeons, if at all possible, at least 1 of them should be willing to talk with you and help you because if you're not giving them this feedback that, hey, I don't know, you're not telling me that it was an extensive maze, you're not telling me that it was an extensive maze. It was rheumatic heart disease, and we're not allowed to guess. We're not allowed to assume. So, it just helps everybody if you give them that feedback on what they can do to improve their documentation. A lot of times, it depends on your approach. Now, I wouldn't necessarily run down in the middle of a, or I say run down because when I was in an office, we were on the top floor and the surgeons and everybody were on the 3rd floor. So, but I wouldn't interrupt them in the middle of a busy office sessions, you know, with their follow ups and their consults and everything else. But what I would do is get a hold of their scheduler and say, hey, can you block me out a few minutes? I need to talk to them. And more than likely, that wasn't an issue. If you're actually not in an office and you're working remote, then, you know, whether it's email communication in basket, something, but you've got to let them know what you need them to dictate if they're not doing it already. All right, sorry, I digress. Let's get back to our nice little gentleman here. Okay, so again, we've got the indications. They also talked about chest tubes. No, okay, let's talk about chest tubes while we're talking about them. In general, chest tubes are included. The only way you can bill separately for a chest tube is if it is well documented that the patient might have had a pleural effusion prior to having surgery. If they come in with that, and it's well documented that, hey, they already had this, and I'm placing the chest tube for that, then absolutely, I'm not guaranteeing you it's going to get paid and it does bundle so you will have to, you know, you're going to have to put a modifier out there. But otherwise, do not code for chest tubes, ART line, central line, none of that, unless there's something outside of this procedure that warrants it. All right, let's get to the heart of the matter here. So let's see, the patient received intravenous antibiotics with 60 minutes of the skin incision, so they'd already opened them up. Transesophageal echo was placed to monitor the patient's cardiac function. I personally reviewed and independently interpreted the intraoperative echoes findings. Overall, there was mild left ventricular dysfunction, right ventricular function overall was normal. Patient has severe pulmonary hypertension. There's also severe mitral stenosis, and the left atrial appendage was free of thrombus. Keep in mind too, some of your facilities may want an actual separate report. So that's going to kind of depend on your facility. I accept this because the fact it is spelled out separately, and it's not enough to say, okay, if he had stopped it, I personally reviewed and independently interpreted the TEE, and there wasn't a separate report, and there were no findings, the surgeon would not get this. All right, but we have 93314 with a 26. Dropping down, they perform endoscopic vein harvesting of the left lower extremity, and that is coded with that add-on code 33508. Vein conduit was of good quality, and then they did a median sternotomy incision, and then the left internal mammary artery was harvested in a skeletonized fashion. Next, let's see, they proceeded with the first portion of the maze. So they encircled the right-sided pulmonary veins, the atrial groove was dissected back to expose the muscle tissue. Using bipolar radiofrequency clamp, they placed five firings to ablate the right pulmonary veins. Then they did cautery to the ligament of Marshall, and then a small left aortotomy was also performed to decompress that left ventricle. Then they encircled the left-sided pulmonary veins, and using a bipolar clamp, they did five firings of the ablation for the left side. Distal portion of left atrial appendage was excised, and then the bipolar clamp, they used that, and then they ablated the left atrial appendage to the left superior pulmonary vein lesion using bipolar clamp for three firings. Next, they placed that clip, which is included, on the left atrial appendage, and then oversew that, and then they opened the left aortotomy, and then using cryoablation, they performed the cryoablation of the roof and the floor line using cryoablation for two minutes. Then they elevated the heart and ablated the coronary sinus pericardially using cryoablation. Then they went ahead and moved on to performing a corresponding mitral valve isthmus line and also used cryoablation. Next, he's going to jump over to coronary artery bypass. He does come back to the maze, so we'll talk about that when we get down there farther. So again, we count distal anastomosis. So the ramus intermedius branch was identified. It was approximately 1.5 millimeter, and that vein graph was sewn to the vessel, and we're going to, we have one vein, so we have the 33517. The LAD was identified distally, and then the in situ lemma was anastomosed to the LAD with the, and then we code that with the 33533. Again, we have to have that add-on code for the vein because this was a combination of an artery and a vein cabbage. All right, next, they dropped down and turned their attention back to the mitral valve. It was exposed from the previous left aortotomy. There were severe mitral stenosis consistent with rheumatic heart disease. Anterior left leaflet was very thickened and foreshortened, and then posterior leaflet was also thickened and foreshortened, although it was not as severe as the anterior. The valve did need to be replaced, so they cut out the valve and then went ahead and put in a new valve. They sized it, and a number 31 was a good fit, so they used a mitrous pericardial valve, placed the sutures, and that code is 33430. Then he goes back and finishes the right side for the maize lesions. Again, cabal tapes were snared. Ventricular arteriotomy was made in the mid-portion of the atrium, and then they performed a tricuspid valve annulus cryoablation. Okay, so again, we have that, this is what's making it extensive, that ventricular aortotomy, and they're working with the annulus cryoablation. And then they did the bipolar clamp on the floor to the right atrial lesions with three firings, and then again they did that to the superior vena cava and inferior vena cava using that bipolar radiofrequency clamp, three firings each. So because this patient is on bypass, we have another, we have an extensive repair, and we have another procedure. We're going to code this with the add-on code 33259. Moving on on this example, this is just basically they closed everything up. I'm not going to spend time on that. So for our codes, we have the mitral valve replacement, and again, that is the more extensive procedure, so I'm going to list that first. And pretty much any more, most of your EMRs, we'll put them in the right order, but I do caution if you do have to add 51 modifiers for your carrier, be sure you're putting it on the lesser codes. Do not put it on your primary. Then we have the one arterial graft cabbage. We have one vein with the 33517. Again, we have that maze, which includes the LAA. I have the TEE N-TURP with the 93314, and then the add-on code 33508, again, with that 59, or it could be X for X modifier for that endoscopic vein harvest. Keep in mind, too, I get this question a lot. If they do that, because they're like, well, I thought you already said that the vein harvesting is included. It is. What we're actually being reimbursed for in that 33508 and the 33509 is for the use of that endoscopic equipment. Again, that's why we don't bill for an assistant with that, because only one person can provide, can actually perform that. Only one person could be looking through. They wear these little glass-looking things that look like little microscopes. Anyway, all right, let's get on to our next patient. This one has severe aortic and mitral regurgitation. We have a redo sternotomy, and we are going to be able to bill that because now we're doing an aortic valve and a mitral valve. And then they're also placing an intra-aortic balloon pump. So for this one, the patient was positioned, prepped and draped in the standard fashion. Let's see, they did the incision over the sternum over previous incision. External wires were identified and cut and removed. That's always a good indication that this is a redo when they're cutting out wires and things like that. So we have the add-on code 33530. Next, they did an aortotomy that was done by direct visualization of the right, of the right-left coronary ostea. And they did, cardioplegian was administered directly into the coronary ostea. They did have incomplete arrests of the heart. Further dissection was then performed to visualize that aortic valve. The aortic valve was excised, followed by placement of a plegiated valve sutures along the annulus. And an additional cardioplegia was given at the time. The valve was sized to a 25 millimeter magnetized bioprosthetic valve. And the valve was sewn into place with arteriotomy. And then that was re-approximated with a continuous running fashion. So now we have the 33405. Next, going through this, the patient kind of started tanking. So they consulted cardiology to read echocardiograms to assess the level of the mitral regurge. And then once the patient was weaned off cardiopulmonary bypass, they figured they were going to need some inotropic support. They noted that the mitral valve regurge was more severe than pre-op. So at this time, the decision was made to replace the mitral valve. So they went on and again, they made the decision with cardiology based on the TEE. Cross clamp was reapplied to the aorta. And then they did some cardioplegia through the SVC and IDC cannulas. Then the sonographic groove was dissected. See, I'm trying to skip through some of this. Sonographic groove was then dissected open, followed by visualization on the mitral valve, which we noticed was structurally intact, but with possibly elongated anterior leaflet. They sized the valve to a 29 millimeter Magna Ease bioprosthetic valve. And that was followed by suturing that valve in place. So we have the 33430. Then left femoral artery intra-aortic balloon pump was put in place. And percutaneously. So that code is the 33967. And then here we have basically the patient was doing well enough. They did not have to place them on ECMO. The balloon pump was enough. So they did secure it. That's down here in this area. So our codes for this patient are 33430, 33405, that redo with 33530, and then the 33967. All right. Got a few more slides here. This is my last case, though. So this one is not so bad. We have left ventricular thrombus, thromboembolism with splenic infarcts. All kinds of stuff. The operation performed is a median sternotomy resection of a left ventricular thrombus. So this patient is 36 years old, had a complex medical history, and has had prior strokes, renal infarcts, splenic infarcts, hepatic infarcts, and has been on Coumadin and Eloquist. And despite all of this, has evidence of a persistent enlarging LV thrombus. So again, we have the TEE probe was placed. One thing I would point out on this one, I would take this back to my doctor and say, look, did you place the probe? Because it's kind of, it's not real clear. I, for purposes of this, since he didn't specifically state that, I only gave him the interpretation. So he personally reviewed and interpreted, independently interpreted the TEE, gave the findings. So we're going to code that with a 9331426. And jumping down, following excellent diastolic arrest, they opened up the patient, right coronary cusp was gently retracted. This exposed the LV thrombus. Retraction was performed then on the intraventricular septum, deep to the right coronary cusp of the aortic valve. And then that mass was traced back to the origin of the LV apex. It appeared to be growing through the cords. Now, this mass again is this thrombus. It's growing through the cords of the mitral valve and there appeared to be some anomalous chordal attachment. This was cut and passed off to pathology. A sponge stick was used laterally on the left ventricle to bring the base of the thrombus into better view. And the large left ventricular mass slash thrombus was removed as one piece. Portion of the tip of the specimen was cut off and sent for permanent pathology. So on this one, we have code 33315. This kind of goes on about what they did before they closed it out. They did continuous irrigation and all of those good things. So our code here is cardiotomy exploratory, which includes removal of a foreign body atrial or ventricular or ventricle thrombus. And that is with cardiopulmonary bypass. All right. And then finally, this is our disclosure stating that again, this is for informational purposes and does not constitute legal reimbursement. You always should check with your practices, attorneys and your local Medicare carrier. And then also your commercial carriers, because remember, commercials don't always follow what Medicare. And all right. And then this is our CPT disclaimer, basically stating that all these codes came from CPT book 2024. And actually, I don't see. There's a comment here. I hope that you you'll have to send this to us because the comment says, I have trouble getting this paid same day as a surgery. I'm not sure which procedure you're talking about. So I would need that redone. And then this question we got. I guess we're a little over. I'll answer this one question. Keep in mind, we will put all the Q and A's together. Probably won't happen until June. We have a holiday weekend this weekend and then end of month. So look for that the first week of June for the Q and A. But patient or patient, one of one of you wonderful attendees commented that you missed my comments on the three, five, eight, two, zero. If the if the patient is taken back to the O.R. for the blade, we can bill the three, five, eight, two, zero. And that would be with the 78 modifier. Basically what I to reiterate that what I had said was. If it's done emergently bedside, then you can still code it as long as it's documented that that's what was done and that they didn't have time to take them to the O.R. And then my other comments about it is make sure if you're coding that three, five, eight, two, zero, that you are actually. It's for thrombus or hemorrhage or infection, otherwise, you know, if they open them up and there's nothing wrong, you can't use that code. So keep that in mind. All right. Well, I thank you all. And again, we'll get those questions together. I hope you all have a good holiday weekend. And I will be back in June with my colleague Tammy. And we are going to cover my favorite Evar, Tvar, Vvar and some open aneurysms. So we look forward to seeing you then. Have a great day.

Cardiothoracic Series 1

heart procedures

valve procedures

coronary artery bypass grafts

left atrial appendage exclusion

mitral valve repair

tricuspid valve repair

coding considerations

congenital conditions

cardiovascular procedures billing

maze procedures

CPT codes

documentation requirements