Hello, everyone, and welcome to our webcast. It's going to be a few minutes. We're going to let people sign on. So we'll get going here in a few minutes. Hello, everyone again, we're just going to wait here about another minute and make give people time to log on for the webcast. Good afternoon everyone and welcome to our webcast. I'm Michelle Platt and I'm joined by my colleague Jillian Bruder, and we will be covering congenital heart CAS and therapeutic services. First, let me go over the Zoom control panel. To access the slides for today's presentation, you need to click on the chat box to access the link here. Please do not 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 and also know that we will answer as many questions as we can during the webcast. We will also compile them and provide the answers in the Academy dashboard on our website. Please note, you must go to the MedAxium Academy, click on the webinar you attended, click claim CEUs to access your certificate. Next slide. The coding CEUs for the AAPC will be available to view and download in the transcription section of the MedAxium Academy account. We are asking for one to two business days to allow time for our team to get the certificates uploaded to your account. Please note, you do need to individually launch the webinar in order to obtain your CEU credits. Finally, this is the CPT disclaimer. All codes from this content are from the American Medical Association CPT. So for our agenda today, we will be covering the anatomy of congenital heart defects, congenital diagnostic casts, repair of heart defects, percutaneous valve procedures, and other therapeutic procedures. So the anatomy, we'll go over that. So what is congenital heart disease? Congenital heart disease is the most common type of birth defects. There have been many or multiple studies over the years that show approximate numbers of yearly reported defects. Congenital heart defects are present at birth and can affect the structure of a baby's heart by the way it works. They can affect how blood flows through the heart and out to the rest of the body. Congenital heart defects can vary from being mild, such as a small hole in the heart, to severe, such as missing or poorly formed parts of the heart. Some congenital heart defects may be diagnosed during pregnancy. Some, however, are not detected until the birth or later in life. Treatments of these depend on the type of severity of the defect. So looking at the anatomy of the normal heart, it's a strong, hardworking pump made of muscle tissue. It's about the size of a person's fist. On the right side of the heart, the right atrium and right ventricle work to pump oxygen-poor blood returning from the body back to the lungs to be reoxygenated. On the left side of the heart, the left atrium, left ventricle combine to pump oxygenated blood back through the body. Congenital defects may involve a valve, a chamber, the septum, an artery, or blood flow issues. Next, we'll cover some defects in detail. So an atrial septal defect is a birth defect of the heart in which there's a hole in the wall that divides the upper chambers of the heart. The hole can vary in size. It may close on its own, or it may require surgery. It's estimated that 13 out of 10,000 babies born have an atrial septal defect. In other words, one in every 770 babies born in the United States each year are born with an atrial septal defect. Corruptation of the aorta is a birth defect in which a part of the aorta is narrower than usual. The narrowing or corruption blocks normal blood flow to the body. This can back up flow into the left ventricle of the heart, making the muscle in this ventricle work harder to get blood out of the heart. It's estimated that about four out of every 10,000 babies born have a corruption. In other words, about one in every 2,500 babies born in the U.S. each year are born with a corruption of the aorta. Transposition of the great vessels is a birth defect of the heart in which two main arteries carrying blood out of the heart, the main pulmonary artery, and the aorta are switched in position or transposed. It's estimated that about 1,250 babies born with a TGA each year in the U.S. This means that one in every 3,300 babies born in the U.S. is affected by this defect. Hypoplastic left heart syndrome or HLHS is a birth defect that affects normal blood flow through the heart. Because a baby with this defect needs surgery or other procedures soon after birth, HLHS is considered a critical congenital heart defect. Hypoplastic heart left syndrome affects a number of structures in the left side of the heart that don't normally, that don't fully develop. So the left ventricle is underdeveloped and too small. The mitral valve could be not formed or very small. The aortic valve is not formed or very small. The ascending portion of the aorta is underdeveloped or too small. Often babies with hypoplastic left heart syndrome also have an atrial septal defect, which is a hole between the left and right upper chambers of the heart. It's estimated that each year about 960 babies in the U.S. are born with hypoplastic left heart syndrome. In other words, about one out of every 4,344 babies have this condition. So a PDA patent patent ductus arteriosus is an unclosed hole in the aorta. Every baby is born with a ductus arteriosus. After birth, the opening is no longer needed, but it usually narrows and closes within the first few days. Sometimes the ductus doesn't close after birth. So failure of the ductus closing is common in premature infants, but rare in full term babies. Pulmonary atresia is a birth defect of the heart where the valve that controls blood flow from the heart to the lung, the lungs doesn't flow at all. In babies with this defect, blood has trouble flowing to the lungs to pick up oxygen for the body. There are typically two types of pulmonary atresia. The first type of pulmonary atresia is with an intact ventricle septum. In this form, the wall of the septum between the ventricles remain complete and intact. During pregnancy, when the heart is developed, very little blood flows into and into and out of the right ventricle, and therefore the right ventricle doesn't fully develop and remains very small. If the right ventricle is underdeveloped, the heart can have problems pumping blood to the lungs and the body. The other type of pulmonary atresia is with with a ventricle septal defect. In this form, a ventricle septal defect allows blood to flow into and out of the right ventricle. Therefore, blood flowing into the right ventricle can help the ventricle develop during pregnancy, so it's typically not as small as in pulmonary atresia with an intact ventricle septal septum. Next slide. Tetralogy of Fallot is a condition caused by a combination of four heart defects that are present at birth. The four abnormalities that make up this defect include pulmonary valve stenosis, ventricle septal defect, overriding aorta, and right ventricle hypertrophy. So pulmonary valve stenosis is the narrowing of the pulmonary valve, the valve that separates the lower right chamber of the heart, the main blood vessel leading to the lungs, reduce blood flow to the lungs. Ventricle septal defect. A ventricle septal defect is a hole in the wall that separates two lower chambers of the heart. Blood can travel across the hole from the left pumping chamber to the right pumping chamber and into the lung arteries. If a VSD is large, the extra blood from pumping into the lung arteries makes the heart work harder and the lungs can become congested. For an overriding aorta, the main artery that's leading out of the body branches off the left ventricle. In Tetralogy of Fallot, the aorta is shifted slightly to the right and lies directly above a ventricle septal defect. Instead of the left ventricle, in this position, the aorta receives blood from both the right and left ventricle, mixing the oxygen poor blood from the right ventricle with the oxygen rich blood from the left ventricle. And with right ventricular hypertrophy, this is when the heart's pumping action is overworked. It causes the muscular wall of the right ventricle to thicken. Over time, this might cause the heart to stiffen, become weak, and eventually fail. Sorry. In babies with truncus arteriosus, oxygen poor blood and oxygen rich blood are mixed together as blood flows to the lung and to the rest of the body. As a result, too much blood goes to the lung and the heart works harder to pump blood to the rest of the body. Also, instead of having both an aortic valve and a pulmonary valve, babies with truncus arteriosus have a single common valve controlling blood flow out of the heart. The truncal valve is often abnormal. The valve can be thickened and narrowed, which can block the blood as it leaves the heart. It can also leak, causing blood that leaves the heart to leak back into the heart across the valve. A ventricle septal defect is a birth defect of the heart in which there's a hole in the wall that separates two chambers of the heart. An infant with a ventricular septal defect can have one or more holes in different places of the septum. There are several names of these holes. Some common locations and names are conoventricular ventricular septal defect, prememorous ventral, or we'll just call it PVSD, the inlet ventricle septal defect, and muscular ventricle septal defect. In general, the conoventricular septal defect is a hole where portions of the ventricle septum should meet just below the pulmonary and aortic valves. An inlet ventricular septal defect is a hole in the septum near to where the blood enters the ventricles through the tricuspid and mitral valves. This type of ventricle septal defect also might be part of another heart defect, an AVSD. Muscular ventricle septal defect. This is a hole in the lower muscular part of the ventricle septum and is the most common type of ventricle septal defect. It's estimated that 42 out of every 10,000 babies born have a ventricular septal defect. In other words, about one in every 240 babies born in the U.S. each year are born with a ventricular septal defect. Okay, next slide. So now we'll do a congenital cath overview. Per CPT assist, as long as there is a congenital cardiac anomaly, it's appropriate to report the congenital cath codes. Age is not a factor with these codes. So for congenital heart cath reporting purposes, once the patient is diagnosed as a congenital cardiac patient, all cath procedures are considered congenital unless aspects of the congenital disease have been removed via heart transplant. Guidelines further state that if a patient did have a heart transplant, but there are still congenital anomalies present, it would still be appropriate to report the congenital cath services. But if no congenital anomalies remain after transplant, then the regular non-congenital codes should be reported. CPT instructions also specify that anomalous coronary arteries, PFO, mitral valve prolapse, and bicuspid aortic valves are to be reported with non-congenital cath codes. Keep in mind, the exception to that is if the patient has other congenital heart conditions in addition to those listed, you will need to code from the congenital cath codes. There are a wide variety of cardiac codes to choose from for billing purposes. These are broke down by three categories, chambers, disease, type, and approach. Included in a cath, the following services are included and considered part of the package of the cath. Cath placement is included, positioning and repositioning of the cath, intracardiac and intravascular pressure measurements, any road mapping angiography, closure device placement angiography. For example, you may see a provider document and try to submit for doing an extremity angiography to see if a closure device is suitable. This would not be billable, will not be a billable service. In short, the provider must close what they opened. Also included would be intracoronary medication administration, contrast injections, and obtaining blood samples and calculating cardiac output. Here are some CPT introductory language on whether the diagnostic cath would be billable. If no prior cath-based coronary study is available and a full study is performed and then a decision was made by the provider at the time to intervene based on the findings of the new study, the diagnostic part of this would be supported for billing. If a prior study is available, but there is documentation supporting the patient's condition has changed, since changed, or there are inadequate findings on the previous study, or if there was a clinical change during the procedure that requires a new evaluation, then it would be billable. Clinical documentation. Clear and specific documentation is a key to correct code assignment. You want to see any access sites clearly documented, any cath movements, where did the cath ultimately end up, where did the cath placement at the time, or where was the cath placement at the time of injections. Any imaging captured from these injections should be clearly documented and interpreted. And what was the intention of the cath? Was it truly diagnostic or was it a staged procedure for an intervention? And of course, any patient history should be documented to establish the medical necessity for the study being performed. So now let's take a look at the congenital cath codes. 93593 represents right heart cath with congenital heart defects, but with normal native connections. 93594 is the same as 93593, except now the patient has abnormal native connections. Normal native or normal connections are when the blood flows the expected course through the right and left heart chambers, as well as the great vessels. Abnormal connections are when the blood flows other paths through the heart. For example, if a patient has the Tetralogy of Fallot, then the blood flow is not following the expected pathway. 93595, we have a left heart cath for congenital defects, and it doesn't matter if the connections are normal or abnormal. Next slide. In 93596, we have right and left heart cath with normal connections, and 93597 is a right and left heart cath with abnormal connections. 93598 is an add-on code for the congenital cath codes, 93593 through 93597. It is used to measure heart function during a cath. You don't report these, though, with cath codes 93541 through 935, or 93461. Next slide. So what are normal native connections? The blood flows along the expected course through the right and left heart chambers and the great vessels. For example, some normal congenital defects are like a VSD, a ventricular septal defect, a PAD, the patent ductus arteriosus. CPT codes 93593 and 93596 are used for these normal native connections. Next slide. With abnormal connections, the blood flows through the heart and great vessels following an alternative path. Cyanosis or cyanotic congenital heart defects include single ventricle transposition of great arteries and total anomalous pulmonary veins. It's very important that your physicians are documenting and letting you know if the patient has a normal or abnormal connection. If it's not documented, these are some examples of things you can look for to identify an abnormal connection. They could be accessing pulmonary arteries through surgical shunts, right heart cath through atrial switch conduits, 93594 and 93597 would be used in these abnormal connections. For transeptal puncture, this code adds on to 93595 and 93597 but does not add on to 93593 and 93594 because those codes are for right heart cath only. Also note that in the description of this code, the septum has to be intact in order to use this code. Here we have add-on codes that can be billed with congenital heart caths when performed. 93463, a pharmacological agent administration, 93464, a physiological exercise study, 93563, injection for selective coronary angiography, 93564 is venous and or atrial bypass grafts and 93565 is selective left ventricular or left atrial angiography. More add-on codes to congenital caths include right ventricular or right atrial angiography, separate ventricular angiography and FFR, which I'm going to go over in more detail in the next slide. So for 93571 is for the initial vessel and 93572 is for each additional. 93572 has an MUE of 2, so it can be reported up to two times. FFR is a Doppler ultrasound that records blood velocity and pressures by measuring the frequency of ultrasonic waves reflected from moving surfaces. You should note that the IFR does not use infusion or medication like FFR does. Codes 93571 include injection of the drug in the CPT code and description. IFR, although similar, does not meet the entire description of the code. So the recommendation is to add the modifier 52 for reduced services since the CPT definition is not fully met for this service. Also note you may see DFR. This as well would need to be reduced with the 52 modifier. Here we have pulmonary add-on codes. Note there are non-selective and new in 2023 there are selective codes. 93568 is for non-selective pulmonary angiography. The codes 93569 and 93574 are selective. Note that 93569 and 9 through 93573 are for pulmonary arteries and 93574 is used for pulmonary veins and then 93575 is a selective angiography of MAPCAS. And with an endomyocardial biopsy 93505, the physician threads a catheter to the heart to take samples of the heart's septum. Guidance does state that if echoguidance is used, you can also bill the add-on service 76932. Do not bill 75970 with this code. Medicare does have an NCCI edit that states in order to bill a right heart cath with this service, medical necessity must be met. The report should support that is medically necessary and a distinct service is performed. There is also a CPT assist article from December 2017 that states the same as the NCCI article. This article states right heart catheterization may also be reported if it's performed for a separate clinical indication and not merely as a means of obtaining the endomyocardial biopsies. In congenital cardiology, specifically with our pediatric patients, we see ultrasound guidance used a lot. It's important to remember ultrasound guidance must have the vessel patency documented as well as having real-time ultrasound visualization of the needle entry and there must be a permanent recording. For example, the statement femoral artery using ultrasound guidance was accessed is not enough to bill this code. There is often confusion around the language, vascular access that would include both the arterial and venous access sites. Now in the CMS National Correct Coding Initiative Policy Manual for Medicare, it states ultrasound guidance for vessel access is included in cardiac cath, coronary intervention, and internal cardioversion procedures if the ultrasound procedures performed for guidance during this procedure. I recommend you check with your non-carrier payers for any policy and guidelines that may have published with billing and this service and with the cath procedures. You may also allow it based on the patient's anatomy and the size of the patient. We'll go on to our case examples. So for my first case here, we have a three-year-old male with a tricuspid artresia, VSD, and severely narrowing RVOT with status post shunt at three years old. So I had put in here, this is an abnormal connection. So we have a right and left heart cath and so we'll go down here. Okay, a venous catheter was advanced from the right internal jugular vein into the SVC and into the branch pulmonary arteries into the wedge position. A prograde left heart cath was performed from the right femoral vein into the IVC, the right atrium through an existing atrial septal defect into the left atrium, the pulmonary veins themselves, and into the left ventricle and aorta. Pulmonary veins were entered from the right femoral vein to the IVC to the LA through an ASD from the right atrium. So on the next page, we have our findings. We have our left upper pulmonary vein, selective injection. We have a right middle pulmonary vein. We have the selective injections into the right middle pulmonary. We have left pulmonary artery injection. We have left pulmonary artery injection, the anominate vein, the SVC, so the superior vena cava, and then the left ventricle power injection into the left ventricle. And these are the measurements. So now we'll go over the answers. So we have 93597 for the right and left heart cath with an abnormal connection. We have 93565 for the injection procedure into the LV. We have 93569 for the pulmonary angiography selective. We have 93574 times two for selective pulmonary vein angiography. 36011 for selective cath placement in the anominate. 75720 for the venography and 75825 for the venography of the SVC. So case two, we have a 14-year-old female with a history of dilated cardiomyopathy who is status post a heart transplant. She presents today for her annual cardiac cath and endomyocardio biopsy. She has been short of breath in the past few months and therefore right and left heart cath is indicated to X, to look at the, you know, everything that she's got going on there. Right and left heart cath and biopsies and coronary studies is the procedure performed. So after obtaining vascular access from the right femoral vein, the right heart cath was performed following four endomyocardial biopsies were obtained from the right ventricle. A retrograde left heart cath was then performed via the right femoral artery. Selective RCA and LCE injections demonstrated normal coronaries without stenosis and unchanged from previous. The catheter was then manipulated to the left ventricle and left ventriculogram was obtained. There was no, there was no pullback across the aortic valve. Okay, so then we go on to their measurements. So for our answers for this case, we have a 9346026 for the right and left heart cath and we have 93505 for the endomyocardial biopsy. So case number three, so case number three, we have a patient with a PFO and they're going to be doing a right and left heart cath and he has his conclusions here. Then our description on the next page. We have local anesthetic was given subcutaneously to the right radial region. Access was obtained via the right femoral artery. The right heart pressures were recorded, then advanced to the PA position for cardiac outputs. O2 sats were then obtained. The thermal dilation catheter was then removed. The thermal dilation catheter was then removed. LV and AO pullback pressures were then recorded. Right coronary selective angiography was then preformed in multiple, multiple views. The left coronary selective angiography was then preformed in multiple views. And then they did give us the moderate sedation with the fentanyl and Versed and his independent trained observer pushed the medication at his direction throughout the 20-minute procedure. And here we have the findings of the right heart cath. We have the LV and the coronaries. So our final answer on this one. So since this case was for a PFO and the patient didn't have any other congenital heart defects, per CPT instructions, this case would be coded with the 9346026 and the 99152 for the sedation. So now I'm going to turn it over to Jolene and she's going to take us through the rest of the presentation with the heart defects and the CT scan. The heart defect repairs and the percutaneous valve procedures and therapeutic procedures. Thank you so much, Michelle. I really appreciate you helping me out with this webcast today and hello everyone. So let's talk about some of the things that are done to fix some of these congenital defects. Now, keep in mind, we do cite Medicare, which CMS is guidance of Medicare and Medicaid, but it's going to be up to your individual states on how they're going to pay for things. It's also going to be up to your commercials on how they want to pay things. I know, of course, I'm not positive if it's still the case because I've been out of practice, out of an office practice for a while, but I know in my state, they will only pay for the primary code and they don't care what else you do. You don't get any reimbursement for it. So that's why we always, you know, we stick with CMS guidance, but that's why we always recommend that you check with your individual carriers. So for one of our repairs for the coarctation of the aorta, we have 33894 and 33895, and that's for the endovascular stent placement for coarctation of the aorta. So the codes are basically split out as to whether or not side branches of the aorta are involved. Also, we have angioplasty only for coarctation of the aorta. All of these codes do include fluoroscopy, diagnostic congenital left heart caths, all catheter and wire introductions and manipulations, angiography of the target lesion, as well as temporary pacemakers. You can report 33897 with the 33894 and 895 if the lesion happens to be in a separate area of the aorta from where the stent is being placed. So if it's outside where you're, you know, where you're placing that stent and you have to do angioplasty at a different site, then you can bill it. Also, other interventions performed at the time are separately reported if outside the treatment area. So for example, if they have to do a carotid or a subclavian stent, since that is outside of the aorta, those could be reported. Let's see. Also, they can't, these codes can also be used with hypoplastic aorta, but again, check with your carriers. So what bundles with these? So as I stated before, these codes include temporary pacemakers. They also bundle with EVARs. So if, you know, now keep in mind when we're talking about these repairs, we're not only talking about babies. So, you know, we do have adults that have congenital defects, and if they open, also happen to have an aortic aneurysm, you do not code these. They do bundle. Non-selective cath placement is bundled as well as aortography supervision and interpretation, as well as any supravalvular aortography and also congenital heart cath codes. Also, do not code the 33897 with a regular stent code 37236, or the regular angioplasty 37246 for any intervention within that treatment zone. And just kind of like the EVARs, the treatment zone contains the graft. So that's reported with 33894 and 33895. So whatever, um, whatever areas that, uh, that graft is contained in, that's your treatment zone. 75573, um, this is for computed tomography of the heart. And, um, this is for, you know, it's with heart contrast material for evaluation of cardiac structure and morphology in the setting of a congenital heart disease. It does include 3D imaging, um, assessment of the left ventricular cardiac function, as well as right ventricular and, um, structure and function and evaluation of the vascular structures if they're also performed. For 3D echocardiography, for congenital echocardiography and congenital transesophageal, we do have this code now for, um, 3D imaging. Uh, this does come up whether or not can we use it with adults. And again, it depends on your carrier. A lot of them are allowing the 3D imaging with that. It just needs to be very clear that that's what was performed. So if you have your, um, TEE, your regular TEE, which is represented down here with the 93312, um, you can build this with that because this, this does add on to that. But when these first came out, a lot of people thought that it was strictly for congenital, but it's not per se. But some carriers, they may not cover it. So I want to talk about the 93355 because this is always, um, this code is used with our TAVRs, our Melody valves, which is our pulmonary valve, timbers, um, all kinds of things. They're also used with VSD and ASD closure. Keep in mind, these are separately billable, but they cannot be billed by the provider that's performing that structural heart repair. So it has to be a separate provider. Some, um, carriers do bundle it and that's mainly because they're, they want to make sure that you're not billing, you know, um, the same provider for the Melody valve and that TEE. Keep in mind, this is transesophageal because ice is separately billable with these, um, you know, with the Melody valve and the TAVRs and all that, but ice is not the same as a TEE. So don't get that all confused. And you also do not report the 93355 with the 93319. All right. So here's some of our percutaneous repairs that we're going to cover. So my question box out of the way here a little bit. So in 93580, a cath is threaded into the upper left pulmonary vein. A guide wire is then inserted and the cath is removed, followed by a balloon, which is threaded over the guide wire, uh, into the position. These, um, pictures are kind of blurry, I apologize for that. But they're going to come in here and thread through this, and they're going to balloon that area. It's going to, you know, they'll balloon it across that defect. The diameter of the defect is then measured, and then they implant the device across that atrial opening, and they'll position that to close that septal defect. In 93581, an occlusive device is placed so that the distal legs are in the left ventricle, and the center of the device is actually in the defect with a slight withdrawing of the sheath, and that'll cause those legs to open up and fill that hole. Both 93580 and 93581 include a right heart cap. It includes injection for contrast for atrial and ventricular angiograms. So codes 93541 through 93543, 9354, I'm sorry, 9355 through 93461, 93530 through 93533, and 93564 through 93566 should not be separately reported. Now, all those codes are in your CPT book, so it tells you what it bundles with, and you can also run it through NCCI edit. For echocardiographic services performed in conjunction with these two codes, you would see the 93303 through 93317 or the 93362. Perceptual defect repairs, these include the right and left heart cath, they include the right and left ventricle, imaging, supervision, and interpretation codes, so any of your 7,000 codes, access across the PFO and the left atrium or ventricle, that's all included. Sorry about that, hold on. So what is separately billable with the septal repairs? You can bill your transthoracic echo, TEE, or ICE. Coronary, aortic, or pulmonary angiography is separately billable. In 93582, we have percutaneous transcatheter closure of a patent ductus arteriosus, and again this is a result of having a patent ductus arteriosus that allows oxygenated blood from the aorta to mix with the unoxygenated blood, so Michelle covered that pretty well in her section, but again the picture on the left shows a normal heart, and the one on the right shows the, you know, the mixing of the blood that's all going on here. So the procedure to repair this that's percutaneous involves threading a catheter into the heart and into that PDA, and then they can use either a coil or some other type of occlusion device, and that's deployed into the PDA. Remember that right and left heart casts are included as well as any road mapping guidance, however for this you can code for your ICE, TEE, and any coronary or cardiac chamber imaging is separately reportable. So we're going to talk about some more here, so we have the percutaneous transcatheter septal reduction therapy, and this is performed to decrease the size of the cardiac septal muscle for patients with hypertrophic cardiomyopathy. So in this procedure, a cath is threaded through the arteries and to the heart, and the coronary angiography is performed to locate the first septal perforator branch of the LAD. So they'll come, I don't have the coronary's picture, well I guess they are pictured here, sorry. So here's the left coronary artery, and then they're going to go here to that LAD, and what they do is they will take a balloon and inflate that balloon within the perforator, and then they'll do a slow injection of absolute alcohol is performed. So this is one of those alcohol septal ablations is another word for these. Diagnostic cath codes can be billed, providing there's no prior catheter-based study. So again, you know, we have those rules with our interventions, if they've already had that cath, you knew that's what you're going in to do, then you're not going to separately bill for that. If they are doing a true diagnostic study, you can bill for it, but we don't bill when it's just for road mapping. And again, you know, it's important for your physicians to document that, you know, if there was a previous study and the imaging isn't good, and they they need to do a new one because of the visualization of the vessels or the atrium, whatever is not conducive for them to do their work, then of course they can bill for that, but they have to document that. Also again, if the patient's condition has changed since that previous cath, or if the patient's condition changes during the procedure. All right, so now we're going to look at the percutaneous valve procedures. And first off, we have valvuloplasty. Now this, I included all of these on here. We have the aortic, the mitral, pulmonary, and the tricuspid. Note that all of these have a 90-day global. You can bill conscious sedation with them, but if you do happen to do another procedure within that 90 days, so let's say for example they did the percutaneous valvuloplasty for the pulmonary artery, and then within that 90-day period, they go back and put in that Melody valve, you're going to have to bill that Melody with a 58 modifier to take it out of, because that's, that's a more extensive procedure than the one that was originally done. You don't want to use 78 in that case, because it's going to greatly reduce the work of the Melody valve, and you don't want to do that. So keep that in mind. It's, it's more appropriate for the 58, because it's, it's a staged procedure. And again, that's only if it's within that 90 days of the valvuloplasty. So this is our code for the transcatheter pulmonary valve that for many years was known as the Melody valve. I believe it still is. You'll also hear it called the TITV. And it's kind of exciting about this, because the Melody valve set the stage for the TAVRs and the set the stage for the TAVRs and the TEMVRs and all of those things, and kind of set the stage for the technology to do these procedures. So it's less invasive for the patients, and it definitely is better recovery time versus having your chest cut open. So what is included with the TITV is all congenital calves, any balloon angioplasty or stenting of the pulmonary valve, or that conduit. You can build an angioplasty or stent that's performed at a separate site that has nothing to do with, that's not related to that actual TITV delivery. Again, that TEE code 93355 can be billed, but it has to be performed by a separate provider. You can also code for ice. You can code for ventricular assist device, balloon pumps, ECMOs, ECLS, or cardiopulmonary bypass. That's all separately reportable. And these are the codes for that cardiopulmonary bypass. They're all add-on codes, and they basically, they're split out by how the bypass is done. So if it's done percutaneously for peripheral arterial and venous cannula, cannula, cannulization, you would code the 33367. If it's for open peripheral arterial and venous cannulation, then you use the 33368. Or if it's done through central arterial and venous cannulation, then you would code the 33369. Again, they just have to document that they place the patient on cardiopulmonary bypass, and then what method that they did that by. If you're unsure, that is something you need to query the physician because it will change your code depending on what approach they used. So I stated this earlier. This does include caths, includes access, includes placing that access sheath, advancing the repair device delivery system into position, and includes repositioning of that device. Angiography and the SNI codes performed for the TIPI are also included. And then any balloon angioplasty within the conduit or treatment zone, and it also includes cardiac cath. So what is separately billable? So again, we can bill a true diagnostic left heart cath, but we have to meet, you know, and that's standard across the board with any intervention, to be honest. Whether you're talking about the heart, peripheral arteries, or visceral arteries, you have to have that true diagnostic need. Otherwise, it's considered road mapping. So some of the other things that we can bill with the TIPI are the pulmonary artery branch interventions when separately performed, any coronary interventions that need to be performed, if a ventricular assist device is placed, and we're talking about our impellas here, if they have to place the patient on ECMO. And remember with ECMO, if they're, when they're placing that, those ECMO, placing the patient on an ECMO machine, you also get to code for the initiation because they have to set that machine up. So you would code the ECMO and the initiation. I'm assuming that the same provider is doing it, but normally if they're hooking them up to the machine, then they're setting the parameters. Now any daily management for ECMO is also billable because that's for managing the machine, but it's not billable the same day as implantation and initiation. Keep in mind too, a lot of providers like to get involved with the ECMO. Only one daily management code can be billed per day. Now your ventricular assist device checks can be billed by multiple physicians, but not the ECMO. So keep that in mind. We can also code for balloon pump insertion. Again, those codes are split out whether or not they're percutaneous or open, depending on how they place them. More than likely the cardiologists are going to do the percutaneous. And then of course, if they perform ICE, that intracardiac echocardiography. So what's some other procedures that they do for these, um, for our congenital patients? So in 33741, this is a transcatheter atrial septostomy, better known as TAS, um, and it is for congenital cardiac anomalies. It creates an effective arterial flow. It does include imaging. And then, um, they use these little, uh, things are the devices they use for these. Um, you'll hear them called a rashkin or a Sangpark balloon or a cutting balloon or a blade. Um, this is the blade version. So, uh, they basically, um, this is transcatheter. So again, it's, um, it does not require, um, any incisions, major incisions into the patient's chest or anything like that. Then we also have transcatheter intracardiac shunt, which is also known as TIS. Um, and this kind of shows how they, they put this, uh, uh, stent, um, you can tell that's a stent there. They place the stent into, um, or shunt basically into, uh, in between the right left atrium. And, uh, that's to help with the, um, for the congenital cardiac anomaly, it helps establish the effective intracardiac flow. Now you have a code for the initial placement and then any additional or each additional shunt. Check your MUEs on that and then check with your carriers on whether or not how many, um, they will allow. And note to, um, on your MUEs, you can find this out too. If there's what they call the clinical data that, so let's say it has that, and I don't know, this is going strictly off the top of my head, so don't quote me. Um, the 33746, let's say that it has an MUE of two, but that the clinical data says three, that means you could appeal it. And then, um, your providers probably have to write a letter and say, Hey, this is why we needed to do three, anything like that. So just keep that in mind with MUEs, but do not quote me that the 33746 has an MUE of two because I don't honestly know off the top of my head. That's something you would need to check. All right. And then we also have percutaneous transluminal, uh, pulmonary artery angioplasty with a 92997. And we have 929, or yeah, 92998 for each additional vessel. Um, this does, I do know the 92998 does have an MUE of two. If it is performed alone and, and not with a cath, you can bill for appropriate imaging codes and cath placements. But if it's built in conjunction with the cath, then you would build the right heart cath and not placements. Um, code 36013 is for the right heart cath placement within the main pulmonary artery. 36014 is for left or right pulmonary artery. And 36015 is for segmental or sub-segmental pulmonary artery. Um, we also have new, uh, for this year, um, our percutaneous pulmonary artery stenting. Again, this is split out by whether or not the patient has those abnormal or normal connections. Um, you're also, uh, we also have whether or not they're unilateral or bilateral. So for, uh, 33902 and 33903, that describes stent placement within the pulmonary arteries, ductus arteriosus, or within a surgical shunt via abnormal connections. The add-on code 33904 is for each additional vessel or separate lesion. Ensure your providers give you clear documentation on this. Um, but you also need to note that this does have an MUE of one, but it does have that, um, adjudication indicator of three for clinical. So you could possibly appeal to, um, bill more of the add-on code 33904. Uh, for 33900 and 33901, those are your native, normal, native connections. And then again, you have whether or not, um, it's unilateral or bilateral. So the normal connections, again, just to reiterate, that means they do follow the normal flow of blood. And if the connections, um, don't follow the normal flow, then they're abnormal. Uh, if the patient has one of those Blalock-Taussig shunts, a shunt, a Sano shunt, or their post-Glenn or Fontaine procedures, those are considered abnormal, um, connections because of that shunt. So again, just like everything else, diagnostic cardiac cath is, um, included unless it's truly diagnostic, or again, if that prior study was done, but if it's documented that there was inadequate visualization or the patient's change, condition has changed either prior to the study or during the placement of the balloon angioplasty. Venoplasty with congenital heart disease are reported with codes 37248 and 37249. Again, this just shows them placing, um, the balloon here with the cath. Um, these codes are, again, pulmonary vein venoplasty when stenosis is documented. They can also be used for coronary sinus or vein venoplasty. Side note, these are not billable with left ventricular lead placement, though, in the coronary sinus. Um, and to be quite honest, this is not really a common coded procedure, but it is there. Uh, so vascular embolization. Note, I do, I show this as coils. These can be done with, um, chemicals too, and I actually do have a case that shows that. But for these, you would code, uh, embolization or occlusion on the vein, venous other than hemorrhage or tumor. So this is for congenital or acquired venous malformations, or you can bill it with 37242 for your arterial congenital or acquired malformations. All right, so let's do some of our cases here. So for this case example, we have, um, patient has a prograde right heart cath, retrograde left heart cath through normal connections. We have a pre, pre-closed device of the right femoral vein access site. We're putting in a 26 sapien 3 valve placement in the pulmonary position, and they've also performed ice. So again, patient presents for cardiac cath for sapien valve placement. If feasible, detailed discussion took place with the patient, legal guardian, and parents, um, prior to the cath. And let's get into the details. So again, the patient was transferred to the cath lab. Um, they were prepped and draped and all that good stuff. Vascular entry was obtained by standard percutaneous technique using ultrasound guidance. Six front sheath was placed in the right femoral vein. Um, a 20 QC was placed in the left femoral vein and a five front sheath was placed in the left femoral artery. And this goes on about the, um, uh, access site and the pre-closed devices. And, um, they also did a complete right heart cath, SVC, IDC, right atrium, right ventricle, MPA, right pulmonary artery, left pulmonary artery. Um, there it goes. So in this case, this is the actual intervention that was done. So basically they placed that 26 millimeter Sapien 3 valve was advanced over the Lunderquist wire through the right ventricular outflow track and the pulmonary valve through the dry seal sheath. They checked with fluoroscopy, confirmed appropriate position of that valve, and it was deployed within the commander delivery system without incident. Balloon was then deflated and removed along with the SF launcher guide cath. That was advanced over the wire into the NPA and pressure pullback was performed. There was no residual gradient across that valve. So our code for that is 33477. And then they did follow up angiogram, then goes on to state that they did intracardiac echocardiography was performed and that showed some right ventricle hypertrophy, but good function. No evidence of pericardial effusion. Pulmonary valve leaflets were thin and mobile without any evidence of pulmonary insufficiency or perivalveular leak. No evidence of atrial shunting. Normal pulmonary venous return to left atrium. Normal tri-leaflet aortic valve without any evidence of regurgitation. So we are going to code the add-on code of the 93662. Keep in mind too that it's not enough to say I performed ice. They need to be giving you, you know, what their findings are within that. And then this goes through what the angiography findings are. And our final codes for this are 33477, which is the TIPV or Melody valve percutaneous approach. And then our ice echocardiography. And again, you're going to use the 26 modifier if you're in a facility. All right. Our next case example, we have a four-year-old with congenital heart disease comprising of coarctation of the aorta and a bicuspid aortic valve. They are status post coarctation repair, which is an end to end anastomosis at age two. A recent exercise test demonstrated abnormal BP response to exercise and a cardiac MRT in moderate aortic arch hypoplasia. So she presents for hemodynamic evaluation and aortic intervention as indicated. So vascular ultrasound imaging was used to define selected vessel patency given the need to minimize vascular complications. Real-time imaging was used during vascular access attempts, including visualization of needle passage into the vessel lumen. Ultrasound imaging was captured and placed in medical record. So we coded 76937. So let me talk about this again real quick. So ultrasound guidance normally with heart caths, anything like that is not billable with Medicare. However, since most of your congenital patients, especially if you're talking about children, they're not on Medicare, they're on Medicaid, or they could be on a regular commercial insurance. So again, that's going to be up to your individual carriers as to whether or not they're going to allow it. And even some cases Medicare probably would if the patient is on Medicare for whatever reason, because of the site, you know, we're talking about a small child here. This is not like accessing an adult's vessels. All right. Let's see. So they did, the access was obtained through the left femoral vein. Catheters were utilized to obtain hemodynamic and oximetric data using standard cath manipulation techniques. They did perform an aortic pullback to obtain hemodynamics of the aortic arch. They also perform angiography in the aorta. Diagnostics were significant for a five millimeter HG gradient under GEDA with aortic measurements as below. We therefore opted to perform aortic stent placement. They exchanged the short arterial sheath for 12 French sheath, and then they gave the child an appropriate dose of antibiotics. Wire was advanced into the aortic root, and a 36 millimeter long LD max stent was then obtained and mounted on a 16 millimeter bib balloon. Balloon stent complex was then advanced to the side of the coarctation. This crossed the origin of the left subclavian artery. Hand injections were performed through the sheath to aid in the final stent position. Then they implanted the stent, and they performed additional insufflation and flaring of the proximal distal portions of the stent. Following this, they put a wire through the side of the stent into the left subclavian artery, and stenting balloon was inserted over the wire and advanced through the side cell of the stent. This allowed patent flow to left subclavian artery, and then they did post stent angiography and pressure measures were obtained. So our code for this is 33984, and again, per CPT guidance with the 33894, we do not report the 93597 for the right and left heart cath. We also don't report any cath placements, nor do we report any of the 7000 codes for the thoracic aorta, nor do we report the 93567 for the aortic root. So if you're, that's all included in that 33894. And you can build a 76937, I apologize, there should be a 26 modifier on that. And again, that's if your carrier allows. So for our last case example, this is a doozy. This is a three-month-old male with congenital heart disease comprising of hypoplastic left heart syndrome, MSAS subtype status post stage one Norwood with a six millimeter Sano conduit. Well, because of that Norwood and that conduit, we know that this patient has abnormal connections. Let's see, vascular ultrasound imaging was utilized to define the selected basal patency given the need, minimize vascular complication. Real-time imaging was used during the vascular access attempts, including visualization of the needle passage into the basal lumen. This kind of reiterates that down here, but they did go on to state that the ultrasound imaging was captured and placed in the medical record. Therefore we would code the 76937. And they performed a right and left antegrade, a right and antegrade left heart via an existing septal opening given the single ventricle physiology and anatomy, oxymetric and hemodynamic data were obtained from the SVC, the IDC, the RA, the LA, both right and left-sided pulmonary veins, the systemic ventricle ascending aorta and descending aorta. That's what, that's what these stand for, these acronyms. Pulmonary vein wedge pressures were measured to approximate PA pressures. So our code for that is 93597. Next they did hand injection angiograms that were obtained within the pulmonary veins. LA pressure pullbacks were obtained from the pulmonary vein to the left atrium, right atrium. Groin catheter was placed in atrium. Pigtail retracted to the ascending aorta, concomitant ventricle ascending, and then descending aorta pressures were then measured. We completed the hemodynamic assessment by performing angiograms in the left atrium, SVC, anominate vein, by selecting and advancing a catheter into the anominate vein to the aortic root, and then selectively into the pulmonary artery sanoconduit by selectively advancing the wedge catheter into the PA. These are all of your codes. I'll break them down on the answer slide. All right, so then they included the SPCs. So from the femoral artery, the physician advanced a four French catheter selective into the right subclavian artery. Notice I struck struck through that, and I'll tell you why, because we're, because we're going to go a little further, but as of at this point, they came up through the femoral and they're coming up here, now keep in mind, this is your anominate, oops, sorry, I didn't mean to click, this is the anominate, which splits then off into your subclavian and your right carotid artery, that's your right carotid going up here, this is your subclavian. So as of now, he's into the subclavian, and he does a shot, and that's why we are coding the 75710. Then, the microcatheter was then advanced into the REMA, so now came from the subclavian into this internal thoracic artery. REMA and LEMA, REMA is on the right side, LEMA is on the left, you could, they're also called internal mammary arteries, internal thoracic arteries, they're all the same. Sometimes you'll see RETA and LATA, it's the same vessel, so keep that in mind, but this is now third order cath placement. So we have the 36017, and then they obtained a vial of 710 to 1000 micron PVA particles, they made a slurry with contrasts and flush, and injected them into the microcatheter to occlude the REMA and right lung collaterals as described. So that is our code 37242, that's our embolization code. So remember, on my picture, I had pictures of coils, but they can also use these, these particles, those chemical particles as well, so keep that in mind. And then these are our cath findings and all of that. And then, of course, these are some more of the findings and the hemo, hemo, hemodynamics, and the angiography. All right, so here we go. So we have the 93597 for the right and left heart cath, and again, remember, we had abnormal connections. We have the 93565, which is for the left atrium or left ventricle angiography. They also did that root supervalvular aortography. So that is represented by the add-on code 93567. We have 93569 for the pulmonary angiography. We have the 37242, which is the vascular embolization or occlusion of the artery, and that was that embolization used with that particle versus just coils. We had third-order cath placement for the REMA, and we have first-order venous cath placement for the innominate vein. We have code 75710 with the 26 modifier and a 59 modifier for the extremity angiography. We have code 75827 with the 26 for the superior vena cava venography. We have 75820 for the extremity venography. Notice that also needs a 59 modifier. And then we have the ultrasound guidance. Again, this is if your carrier allows, and you would need to report it twice because we had right and left side. All right, goodness. So we're going to get to our Q&A portion here real quick. Notice we'll answer what we can. Some of these are probably going to be, we'll have to get back to you on some of that. All right. If you need to send us any questions, in general, you can email all of us. There are several team members now. It's no longer just Jamie and myself. As you've seen, our team is growing. And you can email us at the RCS at medaxiom.com. That way it goes out to all of us. And then whoever can answer the fastest, we'll do that for you. All right. One of the questions is PFO bicuspid. Why are they not coded to congenital? I honestly have no answer for that. It's just that they are not considered congenital defects. I don't even want to make an assumption as to why. But I just know that per the CPT guidance, I even know per Medicare guidance, although it's a defect, it must not be considered serious enough is the only assumption I can make. I don't know. That's actually a good question for your physicians, if they can tell you. But it is in the CPT guidance. It's in the instructions for your congenital cath. That's where we pulled that from. Let's see. This one was a general question. A person's curious if anyone is able to bill for their APPs who scrub and assist on cases in the cath lab. We have surgical first assist APP who scrubs most cases, melody, valve, harmony, etc. And most complex cases. Are you getting a reimbursement for APPs when they assist? If so, email me directly. That's actually in the question and not the chat. If you would actually wouldn't mind putting that on our listserv. And the one thing I want to tell you on the listserv, the BOC and listserv. Keep in mind, again, not all of the rules are the same for, you know, every part of the country. So what works for your state may not work for the person that answers you. So that can be kind of general. Um, there is a list on the fee schedule that will that does show codes that allow for assist. I'm not sure off the top of my head again. If if the melody valve does or not, you'd have to bill that, you know, like if you're talking about billing with that AS modifier. Um, and the thing about that again, if if the code does allow it, but you're still having problems with your carriers, not paying it. You can always appeal, you know, and sometimes you even have to get your physicians involved to where they might have to do a peer to peer review. So anything that does state it allows an 80 modifier. Now, there's two types of that to keep in mind. So there are codes where the 80 modifiers always allow. So, like, for example, right off the top of my head, I know for a fact that coronary artery bypass grafting, which is not what we're talking about here today, but I'm just giving you an example. I know it allows an assistant. Period. No questions asked. Then there's other procedures that allow an assistant. If you have documentation stating why you needed the assistant. So it's not an automatic thing. And that could be what's going on here. And also keep in mind, you need to tell all of your providers. To be sure that they're not just listing the providers that are assisting them. They still need to state their role. Now, the like, when I saw about the cabbage, even though the cabbage assistant has allowed, it's still not enough to just say, you know, Joe Schmo assisted me during this procedure. You have to not you personally, the providers need to dictate what that person's role was. When we're talking about the codes where they'll allow and assist with documentation, what they're talking about here is why did you need that assistant? Again, did the patient have a barren anatomy? What, you know, what was going on that actually required an assistant? All right. I have another question here. What are some examples of separate medical necessity for right heart cath with endobiopsy? We actually had that case that Michelle went over that kind of showed that patient is developing shortness of breath and other things were going on besides just doing that road mapping for the biopsy. So, again, it all comes down to medical necessity. You can always look at local coverage determinations, anything like that. Another question. Does a right and left heart cath require hemodynamics of both right and left like a normal right and left heart cath? Yes, you always have to document hemodynamics, no matter if they're congenital or not. This is always a good question. Would a PFO code to congenital or non-congenital echo? For the, we have bicuspid aortic valve, clear as non-congenital for echoes. Yes, normally that PFO and bicuspid valve are going to fall into the same. They're not going to be considered congenital because you don't have all those other things going on. But again, double check with your carriers because it kind of depends on what they want to do. Let's see. There's a few more on here that we will have to look at. And I will get back to, let's see, this one might be a lantern. Hold on. No, that one. Mm-mm. Case six, third order REMA, shouldn't that be 36217? That is what I called out. Is that not what I said? Oh, it's two ones. That is, that's a typo. Apologize for that. It should be 36217, not 017. Good call. Thank you for pointing that out. You know, we all look at these and we all review them and we're all like, yep, yep, yep, it's good. And then inevitably, every webcast, we have something that comes up as a typo. So yes, all of you, please, if you've printed these out, we will fix this before we put it out on the website as well because this will be, these slides will be available on the website at, in the academy. And we will fix this before we actually put that on there. But if you happen to print them out now, please change that to 36217. All right. Well, that about brings us to the end of our presentation today. Michelle, again, thank you. And we will compile the answers on the rest of these that we did not get to. And hope you all have a wonderful day.

congenital heart disease

anatomy

diagnostic catheterization

repair procedures

percutaneous valve procedures

therapeutic procedures

atrial septal defect

transposition of the great vessels

hypoplastic left heart syndrome

patent ductus arteriosus

angiography

coding guidelines