Hello everyone and welcome to our webinar. I'm going to wait a few minutes to let people get signed in, just a couple of minutes, and we'll get started. Hello again, if you're just happening to sign on I'm going to start here in a little bit we're giving people time to to log in and get get settled and we'll get going. All right, well, thank you for joining us today. This is our first webcast of 2025. And we are going to talk about coding for heart transplants, VADs and ECMOs, which with the VADs that'll include the impellas as well as the open version of our ventricular assist device. So before we get started, this is our, we have the chat button and this is where you can find the link to our slide presentation. And then we also have the Q&A button. Please put your questions in the Q&A box and not the chat box because we do not monitor that chat box for questions. We also ask that you keep your questions on topic and we will answer as many as we can at the end of the presentation. For CEUs, they will be available for AAPC and you will be able to download those in the Academy. They're in the transcript section on your MedAxiom Academy account. And our team will get the certificates uploaded usually within one to two business days. I do see a question that just came in that I'll go ahead and answer. It was whether or not this will be recorded. It is recording right now and it will be available once they get everything. They have to convert things and the team will do that. And that's usually uploaded within a week or two. But back to the CEUs, a couple of things I wanna point out because we've had this come up a couple of times I actually just received not too long ago an email from AAPC that they're really watching to make sure not only are people registering for the webcast, but they also have to be launching the webcast and to get the CEU. Because they've noticed that there's been a lot of copying and pasting for people that didn't actually attend. So keep that in mind. So that is why we used to let everybody listen as a group and do that, but we cannot do that anymore. Those are the AAPC rules, not ours. So just because you register, you do have to launch. We are offering this year, I think for on-demand webinars so that if you can't make the live, you can go back and listen and then answer a quiz and get those CEUs. I think we're doing that for four. And again, this just shows you where you have to go and click and claim your CEU. And like I said, one to two days, those are usually available. All right, so our objectives today, like I said, we're gonna talk about heart and lung transplants, not a whole lot on, I don't have any examples for lung transplants, I guess is what I wanted to put out, but I do have some for the heart, but there was a time and it still could be, there was only certain places that you could do the heart and lung transplants. So not everybody's involved in that, but impellas are quite popular as well as ventricular assist device. And then we have the extracorporeal membrane oxygen support or support services. So those are better known as ECMOs. And most of these devices are used to bridge a patient to transplant. As far as the open VADs and that, impellas are often done to help support a patient that's had cardiogenic shock and things like that. But we'll get into all of that. All right. So this is pictures of an artificial heart. Sometimes these are implanted in patients again as a bridge, but you can see that it's taken the place of the heart itself. And this was just a sliced open view of an actual heart. And then this is where you can see it attaches to the right ventricles attached to the pulmonary artery and then the left ventricle to the aorta. So sometimes they do place these, but if you think about it, these are temporary solutions. These are not permanent solutions. So usually, like I said, they're a bridge to transplant, or it can be to prolong the life of a patient that is not eligible for transplant, but they don't necessarily take the place of a transplant. So for 33927, that is where we actually do a total replacement of the heart system. And again, that's artificial, and that does include recipient cardiectomy. In 33928, that's if they have to remove and replace the artificial heart system. But if they have to revise and only do certain parts of the actual artificial heart system itself, then you have to code that with an unlisted code. And then finally, for the artificial hearts, we have the add-on code 33929, and that's used when the patient has the heart transplant, and then they're removing the artificial heart before they do the transplant. So on that one, you actually, this code adds on to the heart transplant code of 33945. All right, so there's points to consider when we're talking about our heart and lung transplant is first off, are we doing just a heart, or are we also doing lungs? Again, there are the three components. You can remove the heart from the cadaver, and that would be with or without a pneumonectomy. That does include cold preservation of the allograft and perfusing and maintenance of that until they actually place the heart in the patient. Next, you have the backbench work. So that's where they're actually preparing the heart and or lungs to be placed in the patient for transplant. And then finally, you have transplanting the heart itself. And again, there's codes for with lungs and without lungs. So for removal, we have two codes, and this is for the donor heart. And the code is 33930, and that's when the physician removes a heart and a lung or lungs from a donor cadaver. And then again, like I said, they have that cold preserving solutions are infused. And so the aorta and the pulmonary artery, and they remove all this, what they call in block. Now for 33940, only the heart is removed, but again, they still have to use those cold preservation solutions to take care of the heart while it's waiting to be transplanted. Normally depends on, first off, you know, if you think about it, most of these people, they've passed away and they've kept them alive to do this removal. We don't charge those patients. The patients that are charged is either the patient that's actually receiving the heart or some places they have, I know here in my area, there was a place called Gift of Hope, and they would help the recipient with these massive amounts of bills. So a lot of times the Gift of Hope would cover the removal of the donor heart. So just keep that in mind. All right, next we have the back bench, and that's the standard prep. It's performed on the heart and lungs for 33933. And then for 33944, it's the heart only. Now keep in mind, if they have to do any additional repairs to that heart, such as PFO, they might have to do a one vein cabbage, anything like that, that is separately billable. That's not included in back bench work. That's a separate charge. And the codes are listed here on, you know, but it is generally done. And then finally for the transplant code itself, we have the 33935. And again, we're transplanting the heart and lung, and that includes removing the patient's existing heart and lungs, or it's lung or lungs, both can be done. And then in 33945 is just the heart transplant alone. And that is with, again, that recipient cardiectomy. So obviously they have to remove your old heart before they put in a new one. And then also note if a concurrent systemic to pulmonary shunt ligation, or takedown is performed, that's normally going to be done on a patient with congenital issues. That code is an add-on code of 33924. So one of the things I want to point out when we're talking about transplants, you need to double check with your carrier, but as you should know, if you don't know, modifier 62 when it comes to Medicare is only for different specialties. There are some exceptions to that. And one of the main exceptions is a heart transplant, because you, you know, especially if you're doing a heart and lung, you might have one surgeon that's working on the lungs and you have another surgeon that's working on the heart. So that's something you would definitely want to check with your carrier. And see if they allow that, because there is a lot of work involved in transplants, as you will see, as I'm getting ready to go over some case examples. So for our first case, the patient has chronic heart failure, status six. Procedure is a PFO closure of the donor heart, and then orthotopic heart transplant. That's what they call it, orthotopic heart transplant, where you'll see it sometimes as OTH. So for this patient, I start here in the yellow. Once the donor team departed, the donor hospital, they went ahead and made the incision in the patient that's going to receive the heart. This was a redo sternotomy, and the pericardium was dissected. And off of the epicardium, and gradually opened, followed by placement of pericardial stay sutures. Then once the recovery team landed, they brought the heart in, and then there was cannulation of the aorta, and the SVC, which is superior vena cava, and the IVC, which is inferior vena cava. Patient was commenced on cardiopulmonary bypass once the team arrived into the operating room. And then the recipient heart was excised after the cross clamp was applied. They added pacemaker. Leaves were pulled and cut from the SVC. CO2 was used to flood the field. And let's see, dropping down, there was a PFO, which was closed during the back benching with a pledged single suture. Now remember, we can code for that back bench procedure with a 33944, but we also get to code for that PFO closure, because that's separate. That's not something that, you know, is normally part of preparing the heart. So they do get to code for that as well. If you're in an area, now, you know, all of this is gonna be subject to multiple procedure. Some of your carriers do require you to add that 51 modifier. Some will automatically do it, but just know, you know, when we submit a claim of several procedures, they don't pay everything at the highest out or at the highest amount, they're reduced. All right, the first anastomosis was performed was the left atrial anastomotic line at the level of the superior pulmonary vein. This was performed using a four proline and a continuous running fashion. Goes on to say, followed by the next anastomosis to the inferior vena cava, which was also used a four proline and a continuous running fashion. Once this was completed, the pulmonary artery was then anastomosed, again, using that four proline. This is basically, I don't wanna read all of those cause it'll drive you crazy. So basically we have the 33945 is implanting that heart and that is with or without recipient cardiectomy. So we don't bill anything separate for that. And then if you notice farther down after closure of the chest, attention was focused to the pacemaker on the right infraclavicular region. Incision was made over the prior incision of the pocket, followed by excision of the pacemaker leads and the generator. And this was all after the chest was closed. So this was not an open removal of permanent pacemaker and the electrodes. This was actually transvenous. So for this, we're going to code the 33235, which is removal of the permanent pacemaker as well as the electrodes. And this was a dual lead system. So our final codes for this, we have the heart transplant with 33945, the PFO closure with the 33641. I have the removal of the pacemaker and dual leads with 33235. And then the back bench prep of the donor heart with 33944. Now I did not have the dictation for the providers that actually remove the heart at a different location and then brought the heart to this patient. So if I would have, then we could have looked at that dictation and more than likely coded the 33940, but I did not have that. So that will not be coded by obviously the physician that's coming from that other hospital. All right. So case number two, we have, let's see, stage D heart failure, status post HM3 implantation. HM3 is heart mate three. And that is a bad, it's an intracorporal and it was implanted in 2020. So the patient's been waiting for their heart transplant. So for our procedure list, we have a second time reduced sternotomy. No, we don't, we can't code for that redo because of the fact the redo code is only if you're now doing a CABG or a valve procedure. So we're not allowed to code for that. So I would consider the 22 modifier if there's a lot going on with the patient. So just note that this was all in the wishlist. We have the left axillary cut down with explant of ICD. They did a right axillary cut down with arterial cannulation through an eight millimeter graft. And then they inserted brachial arterial lines. Keep in mind, all these lines are included. The central line, swangan, all of this stuff is all part of the global surgical package. And then they inserted a right femoral venous sheath for the venous cannulation. A left femoral intra-aortic balloon pump was also placed. And a right femoral sheath and then an intraoperative transesophageal echocardiogram. A lot going on. So this is the patient's third sternotomy and in the second surgery, which she had the LVAD implanted in 2020. Right groin was used for cut down and femoral cannulation. Ultrasound guidance, we've got a right femoral art line as well as a right femoral venous line. First, we made an incision in the right axillary region and cut down was done. And an eight millimeter graft was then sewn into the axillary artery. So that's where we have the add-on code of the 34716. And that's also to aid in the cardiopulmonary bypass. So this doesn't just have to be used with those of you that do vascular surgeries. This was not just used with EVARs, TVARs, FEVARs, all those good things. All right, with the cardiopulmonary circuit connected, we proceeded with that reduced sternotomy. Incision was made over the sternum with that oscillating saw, followed by dissection to expose the left and right pleural cavities. It's hard for me to read those, this is small on my screen. All right, once this was performed, pericardium was identified, followed by dissection. So this first paragraph is all taking out the recipient or getting ready to take out the recipient's heart. Again, the team arrived and they placed, let's see, cross clamp was placed across the aorta, followed by aggressive dissection to remove the recipient heart. On arrival to the OR room, they did an ABO verification. That has to do with, they do blood typing to make sure that the patient's going to be able to accept the heart. And then, so they did all the back bench prep. So we have the 33944. They also removed the LVAD device after the transection of the driveline. That is coded with 33980. Don't worry, I get into the more details of the bad removals further on in the presentation. For right now, take my word for it, that's the code. Then dropping down, the first anastomosis was performed at the left atrial anastomotic line at the level of the superior pulmonary vein. Again, they're sewing up all the patient's vessels to the new heart. So then we code that with the 33945. And then dropping down, they also placed a balloon pump to aid the patient's heart while they're doing all this work. So we have the balloon pump insertion with 33967. And then sinus rhythm came back. They have good hemodynamics. At the time the decision was made to close the chest after placement of four chest tubes was approximated using sternal wire followed by subcutaneous tissue. The right axillary cut down was closed in layers after the eight millimeter grab. So we have on this one, I also coded that layer closure of a cut down. Now keep in mind, when we open someone up, we have to close them. However, when it's extensive and they're doing layered closure, we would code that with that 35226. It does require a 59 modifier. And then once the, I think instead of once, W-A-N-T-S, it should be once, O-N-C-E. But I take these directly from reports that we have and reports that people send to us. All right, so once the incision was closed, the left axillary cut down was done to explant the AICD. Layers were deepened, the ICD came into view and was pulled out along with, pulled out and with electrocarotid, the wires were exposed, micro sutures were placed around and into the subclavian vein. All the leads were pulled out. Again, this was not done by thoracotomy. This was done extra, transvenously. So we have 33241 for removal of that ICD and 33244 for the removal of the leads by transvenous extraction. A lot going on in these. So these are our final answers. Again, I have the 33945. Consider that 22 for that reduced sternotomy. We have the 33980 for the removal of the intracorporeal VAD. 33244 for the ICD leads by transvenous. 33241 for the ICD, 35226 with a 59 for the repair or X modifier if it's Medicare. For the repair of the lower extremity blood vessel. 34716 for the auxiliary cut down with conduit. 33967 for implanting the balloon pump. 33944 for the back bench. And then again, note, we did not have the dictation for the provider that removed the donor heart. So I did not code the 33940 on this documentation. Okay. This is our last case for transplant. And so this patient has heart failure with cardiomyopathy. Again, this is our wishlist. For the summary, the patient was brought to the OR after informed consent. Again, they put in lines, swung in catheter, all these things. Once the donor team had given clearance to go ahead, the donor heart was suitable for transplantation. An incision was made over the right femoral area for exposure of the femoral artery and the femoral vein, after which the incision was made over the sternum. Sternotomy was performed with the oscillating saw. Again, we have a redo, so I would code that with the 20, I would add the 22 modifier. Keep in mind, I would be careful of overusing 22 modifiers, but it's ultimately up to the carrier, whether or not they're going to pay for it. So you're not wrong in adding it. I will say, if you're not successful in being paid, I would not add it due to the fact that it's going to hold up the entire claim. So like the last case we had with all those codes for the, you know, all the codes that we had going on, none of that would be paid until that 22 is adjudicated. So again, you know, pick your battles. You are, it doesn't increase RVUs. It does give you an increase, usually around 20% of what Medicare would reimburse. All right. So we have the careful dissection was performed in the right and left hemothorax. Pericardium was then dissected, followed by the pericardial stay suture. And again, they're prepping for the aorta, the pulmonary arteries, all those good things. Note on this, this actual report, they didn't really call out that they did a back batch preparation. So that is something I would query the provider on. They did note that there was no PFO, but they did call it out clear. So I would actually query the provider and probably have them do an addendum on that. Okay. Then they go on. The first anastomosis was performed. Again, this whole top paragraph is actually transplanting the heart itself. So we have that code as a 33941. And then dropping down, let's see. They closed the chest. And this is something else I want to point out. They also placed a wound back. You cannot bill for a wound back on a closed incision. It is considered part of closing the patient. It is part of the dressing. That is per the STS. If they had left the chest open and placed the wound back and then they're going to come back later, then yes, in that situation you could. But normally, you know, that wound back on a closed incision is just considered as part of more or less part of the dressing and closure of the chest. All right. So after they closed the chest, focus was then to the ICD. Again, they did that incision was made over the prior incision, which is the pocket. They excise the ICD and the ICD wires. So we're going to code that with the 33241. And then the remainder portion of the LVAD drive line was also removed. I think I forgot to put that one on. Oh no, wait a minute. I know why I didn't. So on the LVAD, if we go back real quick, they did not tell me what type of LVAD. I don't know if it's intracorporeal or extra. So in that case, I can't code. So I'm going to have to query the provider on that as well. So for our final, I have the heart transplant with the 22, removal of the AICD, removal of the electrodes, and then query the provider on the back bench and the LVAD removal, because I need to know what type. And then finally, again, I did not code for the donor heart removal. All right. So now let's talk about ventricular assist devices. So with the advent in technology, we now have, these used to only be open. Now we have the M-PELO for the left heart. We also have a tandem heart for the right. They can, it could be called something else. Tandem is probably the most popular on the right. And then M-PELO, as you can see, this is this, they thread this cath and the M-PELO's in here and it does its stuff. And that helps to aid the heart. M-PELO's are supposed to be placed for the most part. You'll have to check with your carrier, but they're mainly done with a, a cardiogenic shock or some type of severe heart failure. You always want to check if you have an NCD or an LCD, whatever your carrier has, and follow that medical necessity. Keep in mind, these are inpatient only codes. So again, you want to make sure you're meeting that. If they're performing, if they're using a VAD or the M-PELO with an intervention, a PCI intervention, and they have not met the medical necessity, you're going to have a tough time getting that billed. So, and keep in mind, those are expensive. They're expensive devices. So that's a conversation you should have with your doctor. Again, you know, you're not telling them how to practice medicine, but you are letting them know without proper documentation, they're probably not going to be paid for that. All right, so we have the 33995, which is the insertion of the VAD percutaneous that includes imaging, and that's for the right heart through venous access. Then we have the 33992, which is removal of percutaneous left heart VAD arterial or arterial venous cannula. We have the 33990 for the left heart arterial access placement of that M-PELO. 33997 is removal of a right heart VAD. Again, this is all percutaneous. 33991 is both arterial and venous through a transeptal puncture. And then we have 33993, which is repositioning of that right or left VAD. Keep in mind your removals and your repositionings have to be at a separate session and implant. So that example I was talking about where if they use it with a heart cath and to aid in the PCI, and then they remove it in that same session, you only code the insertion. Okay, sorry about that. If they happen to do an open removal, again you're going to, you'll need to choose from those vessel repair codes to cover that, and then you'll also code for the removal itself. Cut down codes are billable with the 33990-33991 via that femoral artery, iliac, brachial, or auxiliary slash subclavian. Keep in mind, even though the code specifically states auxiliary, the subclavian is also allowed to be used with that code. Cut downs are mainly performed by the surgeons, and then there's also codes that are cut downs with conduit placement. So in those situations, they actually put in a piece of graft, they put in that conduit to open that vessel up bigger so they can maneuver the devices in place. All right, so one of the things that came out, so this is a scenario for conduit use with that percutaneous left heart vads. We're talking that impella because it's percutaneous, and this would be if the surgeon themselves, let's say a CT surgeon performs this, they put in that percutaneous impella, they use an auxiliary graft with a conduit, this is just an example. This is not everyone, this is just pure example. Or if they do a direct aortic puncture, then you would have to use an unlisted code because they don't have that. But here's what still makes it percutaneous. So even though they're cutting into the artery, and they place that conduit, they puncture the conduit, which makes it percutaneous when they place that impella. So I know when these first came out, and you know, there was all kinds of questions. I mean, those of us in MedOxium are having questions as well, and then in having discussions with the STS, this all kind of got ironed out. Because I do know for a while, the manufacturers were saying, oh, code these as open vads. They're not. A vad and an impella are, you know, a heartmate three, and I'll, you'll see later, I have pictures. These are not the same thing, nor is it the same amount of work. So this is a scenario that you would use if it is a CT surgeon, and they're putting in this impella while they're performing a CABG, or whatever else they're doing. Rarely is a CT surgeon just going to do this without doing something else by themselves. Now, the other scenario that is common is we have a cardiologist and a surgeon doing these together. So the surgeon comes in to do that cut down. They assist the impella being placed, and the cardiologist actually places the impella. Well, unfortunately, the 34716, which is the most common, they most commonly do that through the axillary artery, does not add on to 33990 with an 80 modifier. The impella is not allowed to be billed with a 62 modifier. So in this situation, your cardiologist is going to bill for the impella. Your surgeon is also going to bill for the impella with the assistant, but now they have to use an unlisted code to account for the axillary artery with conduit, or if it's the femoral, whatever way they go. When they do that cut down with the conduit, it does not add on to a code with an 80 modifier. All right. Now we're getting into the actual ventricular assist device, like your heart mates that are being done open. So as you can see, this is like, you know, this shows you what the single ventricle looks like. This shows you the biventricular with the extra corporal. Well, as you can see, this is not the same as an impella. Nowhere near shape, weight, or form. So that's why when the, you know, when the manufacturers were originally coming out advising that, the STS was like, no, no, no, no, no, no, no. This is not the same thing. So keep that in mind. Now the difference is on the left, again, we only have the single ventricle and then on the right, but don't let that throw you off. It doesn't have to be, this shows right and left. It's because they're just showing that it'd be either or on this picture. If it's by V, it's this, and you know, this is the drawing of it. And this actually shows a patient with it. All right. So these procedures more than likely are going to require cardiopulmonary bypass. So when we're doing the extra corporeal VAD, that means the pump, the device, the drive lines, and the cannulas are all outside the body. And we have 3, 3, 9, 7, 5 is the insertion for either right or left. And then 3, 3, 9, 7, 6 is when they're doing a by V. So that means they're doing both right and left ventricles. Now keep in mind, we're talking extra corporeal, um, both right and left. They can do an intra and an extra, but that's not coded as a by V because it's two different things. Because remember on that, um, the extra corporeal, that's all outside of the body for the most part, the intra it, it lies inside. Okay. For 3, 3, 9, 7, 7, we have removal, um, single ventricle or 3, 3, 9, 7, 8 is for the by V. And then again, we're talking the entire system. Cardiopulmonary bypass is required while the pumps and tubes and devices are removed. Any holes that are in the heart or vessels are closed. That's all included when you're removing these. And then cardiopulmonary bypass is discontinued when the patient's heart function returns. Sometimes they will place a balloon pump to assist in that. And then for code 3, 3, 9, 8, 1, the replacement of the pump or pumps includes removal of a previous pump and insertion of a new pump. If they do percutaneous transseptal access for that replacement, you have to use an unlisted code. All right. Then for the intracorporeal bed, you'll only have drive lines on the outside of the body. And then they actually create an abdominal pocket and that contains the pump and the rest of the device inside the body. Again, um, when we're talking about the intracorporeal, they're usually heart, some type of heartmate, usually the heartmate three. Now, um, again, you're going to have cardiopulmonary bypass for insertion and removal for insertion. We have the 3, 3, 9, 7, 9, and it's either the right heart or the left. It's only one ventricle, not both. Uh, and like I said, sometimes they'll place an intracorporeal on one side and then they'll do extra on the other ventricle. 3, 3, 9, 8, 0 is removal for that single ventricle and 3, 3, 9, 8, 2 is replacement of the device pump itself without cardiopulmonary bypass. Or if they use cardiopulmonary bypass, then you code the 3, 3, 9, 8, 3. So if they happen to have a thrombus, um, in the, uh, ventricle while they're doing this, if a separate heart incision is performed, then you can code the 3, 3, 3, 1, 0. Uh, that's without bypass and, um, with bypass, you would need a 59 or an X modifier in conjunction with those open BAD codes because of the fact that's included. So you have to, um, you have to distinguish that one out with the 59. If they don't use bypass, you don't need the 59. And then we also have, um, uh, BAD interrogation. Now this can be used for, uh, the heartmates, the impellas, whatever the case may be. Keep in mind when it comes to a BAD interrogation, more than one provider can perform this in the same day. So it can be multiple providers multiple times during the day, same day. Um, it has an MUE of 4. If it's the same provider doing multiple things or multiple times, they would bill with a 76. If it's a separate modifier, you would use a 77. So sometimes, um, now this gets sticky when you got a lot of different providers involved because it depends on who gets their bill in first. But, um, you know, a lot of times cardiologists and CT surgeons will monitor these or, uh, your physician assistant. They have to be a qualified provider, um, or a physician. They need to be documenting parameters such as drivelines, the alarms, power surging. They have to review device function. There should be statements about flow and volume status, that type of thing. If they have to program, that also, also should be, um, reported. You do not report these though as the same day as insertion or replacement. Also note you can report it the same day as an E&M service. Your E&M service is going to require a 25 modifier. And keep in mind the reason why is when they're doing this VAD interrogation, they're treating the machine where the E&M service is actually taking care of the patient. But there has to be documentation to support. If they're only doing that VAD interrogation, then you're not also going to bill an INIT. All right, so again I have some case examples. So this first one we have, um, this is a cardiologist and a surgeon are involved. Um, down here in number three it says assisting cardiologist with auxiliary impella insertion is doctor and it's blank. So we have a patient that has cardiogenic shock, severe mitral regurgitation with worsening function. So they made decision for auxiliary impella placement for the management of the shock. Um, so we have an incision was made over the right delto-pectoral groove. Bovicotery was used to dissect through the pectoralis muscle and then the pectoralis minor was divided. We were then able to apply or identify the neurovascular bundle and separate the subclavian vein and brachial plexus from the subclavian artery. This was controlled and proximally and distally with, as heparin was delivered. Clamps were placed both proximally and distally and the artery was opened. Then a 5.0 proline suture was used to create an anastomosis with a 10 millimeter gel weave graft. Once this was complete, the graft was de-aired and homostasis was assured. Um, so I have the 33999 and I'll explain why. Basically I can't use the regular cut down because we have a cardiologist and a surgeon doing this. So I have to use the enlisted code with this auxiliary cut down because then it goes on, um, we'll just call him Dr. Seuss performed the impella and I assisted. So further on it goes, the impella was inserted across the anastomosis with some difficulty but was finally able to cross the arch without any issues and placed in the left ventricle. A wire was removed, impella was activated in position, was assured based on TEE and bronchoscopic guidance. Once this was assured, the graft was shortened and secured to the impella device. So we have the 33990 for the impella and we have the three, that's for the cardiologist, and then we have the 33990 with the 80 for the CT surgeon. The CT surgeon in this dictation did not document the bronchoscope, so, um, or any of the, you know, the findings were actually placing it, nor did they, uh, document findings on the TEE, so I'm assuming, um, that this was done by the anesthesiologist. If it was done by the surgeon, this does not constitute enough documentation to bill for those. So, again, our final codes are the percutaneous heart vat, left heart vat with the cardiologist with the 33990, 33999 for that auxiliary graft with conduit with the CT surgeon, and then the percutaneous left heart, um, vat, the impella, 33990 with that 80 modifier. Okay, so case number five. Now they came back and actually removed, this was the same patient, but the surgeon removed it by himself, so, um, he gets all of this. So they had the prior incision at the deltoid pectoral groove was injected with local combination of lidocaine and marcan. They reopened the incision, gained access to the graft, which was manually controlled. The impella device was then placed on P0. We pulled out our graft without difficulty or issues. Patients tolerated it well. We then back bled the graft. There were some areas of clot which were removed. The rest of the graft was then brought from our counter incision out, and we repaired the artery and layered. I probably should also say incision. So we have a repair of extremity artery direct with the 35206, and then the removal of the left heart ventricular assist device. And again, this is just the final answers, and that was done by the CT surge. All right, case number six. Um, this one we have patient received, um, I can't read that, uh, small on my screen. Anyway, they gave him something for conscious sedation. Independent trained observer administered the medication and the patient's level of consciousness and response throughout the procedure was monitored. Entry service time was 30 minutes. This got left off. You should also code the 99152 with this patient. The impella left ventricular assist device was removed from the left femoral access site to perclose, which had been placed prior to the insertion. And then the patient tolerated the procedure. So this was just successful removal through a percutaneous left femoral site. So on this one, we would only code the 33992. But again, please note that it also, you could code the moderate sedation. Case number seven, we've got a lot going on here. We have, this is coronary artery disease. This was all pre-op, acute myocardial infarction, status post-emergency coronary artery bypass grafting with direct aortic impella, left ventricular assist device for mechanical circulatory support, post-cardiotomy shock, acute systolic heart failure, severe LV dysfunction, history of marijuana, and then intramax profile number one. So they're performing a right axillary artery cut down with the conduit, percutaneous insertion for cardiopulmonary bypass, redoing a median sternotomy, implant of the heartmate three, which again, that's intracorporeal, insertion of the extracorporeal centromag, right ventricular assist device, TEE with interp, reconstruction of the pericardium with two millimeter Gore-Tex membrane, insertion of the right femoral artery line, modifier 22 as indicated. And then they did open removal of the direct aortic implant. All right, this is actually a surgeon doing this as well. So, um, in the description, they dictated transesophageal echo was placed to monitor the patient's cardiac function. I personally reviewed and independently interpreted the intraoperative echo findings. Overall, there were severe LV dysfunction, right ventricular function was mildly reduced. The aortic impella was in appropriate location, no LV traumas. So we have the 93314 with a 26. Caution you on these TEE interps that are performed by a surgeon, make sure that the cardiologist and or the, um, anesthesiologist is not also reporting this. Most, most of the time you'll have an agreement in place. This particular group, I know that they do have it. And the cardiologists do not balk at the CT surgeon actually performing the TEE interp. And it clearly states that, you know, um, that they personally reviewed and independently interpreted, plus they gave me findings. All right. Dropping down, we have that eight millimeter gel we've graphed. And, um, that was sewn to the right axillary artery. So we have the 34716. It was connected to the arterial limb of the cardiopulmonary bypass circuit. So again, this was done to aid in bypass. Um, next they did that incision. They did a redo, but again, we're not doing a cabbage or a valve. So you're going to look at the 22. Further down, the aortic impella was turned down for lower setting. And then they were able to identify the aortic impella graft, mobilize and control it. So we have the 33992 for that. And then next we have, um, this is a long case. So I'm just reading the yellow left ventricular assist device was then brought into the field inserted, um, through the left ventricular cavity via the apical sewing ring. The locking mechanism was engaged. I inspected the apical sewing ring and it was, um, hemostatic lap pads were removed and we lowered the left ventricular assist device into the appropriate location of the left cavity left chest cavity with the heart field. I also measured and cut the outflow graph to the appropriate length for it to lie alongside the diaphragmatic service surface and around the right atrium. And then they proceeded with placement of pulmonary artery graft and AR, um, arteriatomy was made in the proximal main pulmonary artery. And then they added an eight millimeter gel wave graph. There is no code for that. So that is an unlisted code. And then go on with, um, the anastomosis to the pulmonary artery. And the graph was later tunneled to its epigastrium for the insertion of the extracorporeal RBAD, um, and they go on and extend the arteriotomy to fit the LVAD graft. Then they tunnel all of this stuff and put all of this stuff in. I'm going to kind of run through this because, um, I don't want to run out of time. I have to leave time for Michelle. So for this, we have the three, three, nine, seven, five with the 22 modifier, which is the insertion of the intracorporeal LVAD. And then we have the three, three, nine, seven, five. We need a 59 or X because they do bundle and we have insertion of the extracorporeal RBAD. So one's on the left is internal. The one on the right is external. And then these are our final answers on this. Again, we have the insertion of the VAD with the 22 insertion of the extracorporeal on the right, the axillary graft with conduit, the pulmonary artery with conduit, removal of that impella, and the TEE interpretation. This is my last case. And this one is fairly simple. This is actually, uh, the nine, three, seven, five, zero. Um, I'm put the 77 modifier because, um, there's, I didn't show you the whole note, but there was other dictation from cardiologists earlier that day. This again was done by, um, a surgeon and they documented, uh, the impella insertion, increased ectopy with decreased impella flows requiring the impella to be repositioned. They go on and list all these things about the impella and go on to talk about, um, the flow, no alarms, no clot, et cetera. All right. I am now going to turn this over to Michelle and she is going to take us through ECMOs. Thank you, Jolene. That was great. Um, so before we dive into the codes, if you can go ahead and go to the next screen, Jolene. Um, before we dive into the codes, we're going to take a look at the extracorporeal membrane oxygenation circuit. So ECMO is a treatment that uses a heart and lung machine to provide support to the heart and or lungs when they become too weak to support the body's needs in the picture. In this picture, it shows the two different methods used to accomplish an ECMO circuit On the left, it shows a veno arterial ECMO. This circuit takes over the function of the heart and the lungs. A cannula is placed in an artery. Then another is placed in a vein. Blood is then pulled from the vein through the oxygenator where the blood is oxygenated and sent back to the body via the artery. On the right is the veno venous ECMO. This circuit is used for lung support only, and it only requires one or two cannulas, which are placed in a vein. Blood is pulled from the vein, oxygenated and sent back to the body through the vein. Okay, next slide. Oops, I went too far here. Here we have the different methods for placing the cannulas. 33951 and 33952 when done percutaneous. 33953 and 33954 when they're done open. 33955 and 33956 are done by sternotomy or thoracotomy. Note on these codes that age is a factor when reporting these. They go like birth through five years of age and six years and older. Also note that fluoroscopic guidance is included when done with these codes. Next slide. These codes are for ECMO initiation. 33946 is for veno venous and 33947 for veno arterial. These codes are reported along with the cannulation insertion codes 33951 through 33956. The initiation ECMO settings such as the device components, blood flow, gas exchange and other necessary parameters for the circuit should be documented in the op note. If the provider just documents ECMO initiation, this would not support reporting the initiation code. Next slide. The ECMO circuit requires daily management. These codes depend on the configuration of the circuit. 33948 for a veno venous circuit and 33949 for the veno arterial circuit. Daily management of the circuit and parameters includes management of blood flow, oxygenation, CO2 clearance by the membrane lung, systematic response, anticoagulation and treatment of bleeding, cannula positioning, alarms and safety. ECMO usually involves multiple physicians and supporting non-physicians to manage the ECMO circuit. So with that being said, only one provider can build the daily management code once per day. We can build daily management with E&M services because the management pertains to the ECMO machine and the E&M service pertains to the patient. Also note that these codes should not be reported on the same day as the initiation codes. Next slide. There may come a time during ECMO treatment when repositioning of a cannula is needed. A few examples could be a circuit malfunction, low flow limitations or a clotted circuit. If repositioning is done, the code will depend on the method and the age of the patient. If repositioning of a cannula is done in the same session as an insertion, it's not separately reportable. Also, they should not be reported on the same day as the initiation codes 33946 and 33947. And fluoroscopic guidance is included with repositioning as well. Next slide. Once the patient's lung and or heart function has recovered, the physician will wean the patient from ECMO by removing the cannula. This is where these codes come into play and to be reported on the method used and by the age of the patient. So you have 33965 removal of peripheral, percutaneous, you know, birth through five years. Then you have the ones for the open and then your sternotomy and thoracotomy removal. Next slide. There may be a case where the provider needs to create a graft to facilitate arterial perfusion. This is where 33987 could be reported in conjunction with 33953, 33954, 33955, or 33956. And 33988 is when a venting catheter is placed in the heart through a chest incision to assist during ECMO insertion. And 33989 is the removal of that left heart vent. Next slide. Here we have some other cannula scenarios. Replacement of a cannula in the same vessel is reported using the insertion codes only. If a cannula is removed and replaced, I'm sorry, if a cannula, if cannulas are removed and are placed in different vessels, report with the appropriate removal code and the insertion code. If an extensive repair or replacement of an artery is needed with cannula removal, the appropriate appropriate blood vessel repair code may be reported. Note that 35266 is not separately billable with the removal codes 33969, 33984, 33985, and 33986. Next slide. Excuse me. So now let's go over a few case examples for ECMOs. Here, the procedure is an insertion of a veno arterial ECMO using a 19 French arterial cannula in the right femoral artery and a 25 venous cannula in the left femoral vein. The surgical team was present at the bedside for emergent cannulation of initiation of a VA ECMO after the patient was positioned, prepped, and draped in a standard surgical fashion, followed by a routine timeout, percutaneous access to the femoral artery on the right and left femoral vein was accessed using ultrasound. Heparin was given at this time about 5,000 units, followed by sizing of a 5 French catheter using saldingular technique to a 19 French arterial cannula on the right femoral artery and a 25 French venous cannula on the left femoral vein, followed by a cannulation of the ECMO circuit, the arterial and venous limb, followed by initiation of VA ECMO at bedside. Next slide. So our answer for this case, we have 33952 for peripheral insertion percutaneously for six years and older. And note in this example, we didn't have supporting documentation for the initiation of the ECMO, so I didn't code for that and we would query the provider on this case. Next slide please. This is a, this patient has a, is chronogenic shock, status post type A dissection repair, and the left, or LM stenting. So after they had the type A aortic dissection repair, the patient had an uneventful night, but in the morning developed features of cardiogenic shock. So they decided to take him to the operating room to place a VV ECMO. So a veno venous. Access to the right internal jugular was done under ultrasonic guidance, an eight front sheath was placed under fluoroscopy. The balloon tip catheter and the sheath were taken out, keeping the wire in place under fluoroscopy. The track was dilated to size 30, and then the PROTEC duo was inserted under fluoroscopy. This was confirmed by TE. The tip of the PROTEC cannula was in the main pulmonary artery. Placement was confirmed, wire was withdrawn, and then ECMO tubings were connected to the PROTEC duo, making sure that no air bubbles were in the tubing. VV ECMO was initiated at 21, or I think that's 2 LMP. The saturation come back to 100%. The PROTEC duo was then fixed to the skin at multiple places with silk sutures. The flows were then adjusted according to the blood gas and sweep gas at 2 LPM. Next slide please. So for our answer on this one, we have 33952 for the insertion of peripheral percutaneous cannula, six year and older, and we also have the 33946 for the initiation of the veno venous ECMO. Next slide. For our last case, we have here where they're doing a decannulation of a veno arterial ECMO. So this is a 71 year old, status post salvage mitral valve replacement, and she had coronary bypass grafting and required a veno arterial ECMO, and now she's presenting for decannulation. So, next slide please. She was brought into the operating room from the ICU after clamp trial, decision was made to proceed with veno arterial ECMO decannulation. Incision was made over the superior cannula within the first groin and the bovine cardi, artery used to dissect through the subcutaneous tissue. The first, the vein was isolated and the purse string was placed around the cannula. We then isolated artery, clipped proximally and distally and placed red rubbers. It was extremely difficult, secondary to old blood and excessive tissue. Once this was complete, we removed the venous cannula after clamping successful, and then recirculated the volume back to the patient and controlled the greater staphenous vein with a five proline suture. We next remove the arterial cannula and control it proximally and distally, and excellent return proximally and distally and release the pressure. We then primarily closed the vessel transversely with proline sutures in two layers. And once hemostatis was achieved in the groin, it was closed in layers and staples were used on the skin. And then the patient was returned back to the ICU. So our final answer on this case was 33984, removal of peripheral cannula open six years and older. So this is our disclaimer stating that this is for informational purposes only and doesn't constitute legal reimbursement, coding, business or other advice. You should always check with your local Medicare carriers and consult with your practice's legal counsel for coding and reimbursement advice. And finally, this is our CPT disclaimer. And now we'll bring Jolene back and look over some of the questions. All right. So again, the recording will be available with probably within a couple of weeks. We've had a couple of questions here. One is what is the difference between 33967 impella balloon pump and 33990 VAD impella device? I have never heard of an impella balloon pump. I'm possibly that's a typo from your physician because balloon pumps and impellas are not the same thing. I would definitely query the provider on that one. So like I said, it could be he called it that or he or she called it that in their dictation, but they're not the same thing. Another question was, can we use a 93750 for the interrogation with the impella? Yes, that is the 93750 was used for the open VADs and the impellas. Another question about that. The MUE is at four. They're asking, is that per specialty? They actually have different specialties they're running into or different specialties are trying to code the interrogation. So they have a CT surgeon, cardiologist, pulmonary. And the question was, could all three charge the same day? Yes. The short answer to that is yes. MUEs usually have nothing to do with specialty. So that is, you know, the MUE is how many times that device can be or that particular code could be built. Now there are some, you have to look at the clinical data to see if it allows for more and you could possibly appeal if it does, if it has that status of one. But note on these, the different specialties can be involved and usually they are. You'll usually have, you know, at least the cardiologist and CT surgeon. And then of course, you know, pulmonary can be involved as well. Bottom line is if you happen to own all of those specialties, or even if you don't, again, you're going to have to try to figure out who coded first. It's usually simpler when you have the cardiologist with the CT surgeon and the same practice, because you can look and you know, you can look in your EMRs and your billing system to see did the cardiologist bill it first or did the surgeon. Whoever bills it second would then need to use a 77 modifier if it's a different provider. If it's the same provider doing it multiple times, then the first one would be without any modifier. And then how, you know, if they go in three more times that same day, then you'd have to bill it with the 76. But once you start having other specialties involved, the MUE itself does say four. And if you get a denial that, you know, too many of these were reported, you can try appealing. But sometimes that just comes down to the nature, you know, of what's going on with that. Someone also commented that the AMA published clarification on wound vac in October 2021 CPT assistant, stating that it's considered billable for both open and closed wounds. I had not actually seen that article. I will say, however, the SDS has stated not to code it. But I will go, I will go get clarification on that. And you know, I mean, obviously, the AMA is going to overrule SDS. So it's quite possible they hadn't seen it yet either. Oh, question was, what needs to be documented for initiation of the ECMO? Michelle had that example. And she had one of those as an example. They just seem to say that they initiated it and, you know, what the parameter was, that type of thing. Nothing too fancy with that. Let's see. Oh, going back to removal of percutaneous LVAD through an open femoral exposure, what is required documentation to build both the 33992 and the 35226? Well, when we're talking about the impellas themselves, the percutaneous VAD, they have to document that they remove because that 33992 is actually a percutaneous removal. So you have to account for removing the ventricular assist device. And then you also then document that the artery was repaired and that the wound was closed. Because 35226 is, is that the one with the graft? One of them's direct, one's with a graft, one's lower extremity. I don't know them all off the top of my head. But basically you have to, they have to document that they repaired that artery and did a layer closure, that type of thing. So in that case, you know, and again, that's normally going to be done by a, either a CT surgeon or vascular surgeon, because they're going to be the ones doing the repair of that artery. This question is what do you code for new cannula and or removal of non-functioning cannula? There are no codes for those. So you would have to, you know, again, you're going to have to code that with unlisted. You'll have to discuss that with your provider as to what it compares to. We say that a lot here at MedAxiom. And the reason why is the provider is the one that knows. Now, obviously not all of them know the codes. So you're, you're probably going to have, you know, to say, Hey, what other type of procedure would you compare this to? If you have one that has extra time and you take your book with you and they're willing to look at it. Which is how I learned a lot from CT surgeons when I was working with the surgeons. But anyway, long story short, the physician knows best what it's going to compare to as far as length of time. That's why we legally, because we, you know, we at MedAxiom, that's why we have our disclaimer. We can't give you legal advice on those. Now, obviously when you're talking, you know, the auxiliary cut down, because it doesn't add on to the 33990 with the 80. Well, we know that's what we're doing. So in that unlisted code, you can compare it to the auxiliary. So that type of thing I can flat out tell you. Well, when you're talking about a procedure where it doesn't actually have a CPT code, like the changing out of those cannulas, then you're going to have to discuss it with a physician on what they feel it would best compare to. When you say type of left ventricular assist device, are you referring if HeartMate, HeartWare brands, there's a lot of different brands. HeartMate 3 is what I'm seeing the most right now. But it's a matter of the Impel is the Impel, that's percutaneous. But the different ones for the type of LVAD, again, it depends as an intra, as an extra corporal, that type of thing. And I've had a question, why didn't I remove the pacemaker or why didn't I code 33233 as well? I believe that code description 33235 says for the pacemaker and the leads. But I will double check that before we publish the slides themselves. And we will look at that from there. Let me see what else we have in here. If patient is placed on ECMO, wouldn't initiation be done at that time? Theoretically, yes, it should be. You know, if they're put the ECMO on, they should be doing the initiation, but they do need to dictate that they did it. We're not allowed to, you know, assume that they haven't. I have anonymous attendee asked me, do I have information on outpatient coding for external VAD equipment that would help with reimbursement rates? I'm not positive. I'm not positive what you're talking about here. If you want to email RCS at medaxium.com with more specifics, you can do that, and we will be happy to look into that for you. Is ECMO initiation always billed by the CT surgeon or whoever cannulates the patient? Have you ever seen a critical care doc, for example, document and bill the initiation? The short answer to that is normally no. Whoever usually puts in the ECMO is the one that initiates it, but if there's a situation where a critical care doc ended up doing that, I'm not going to say that it's not possible, but it should be clearly documented. But normally, you know, once you're putting them on ECMO, now again, if it's done percutaneously, it could be the cardiologist. Just depends on who does it. So I, you know, I never say never, that type of thing. So I would just kind of, Michelle, do you know anything different? Have you seen any? I have not seen that so far. I don't think that would be common, but I do know when you get a lot of different groups involved, they groups involved, they, yeah, they do like to, they all like to get in and jump in the pond and swim around. I think, yeah, I did answer that one, that the 93750 is for open VADs and impellas. So, all right. Well, that looks like the majority of our questions. So I appreciate your time and attention. Nicole will be doing, the topic has slipped my head, but I do know Nicole is doing a webinar in March. Tammy and I are coming back in April. I'll have my colleague, Tammy Baron with me, and we are going to go over the ever popular pulmonary thrombectomy procedures, because those are definitely challenging. So again, give me back a few minutes of your day and appreciate you attending these webinars. Thank you. Thank you.

heart transplants

ventricular assist devices

extracorporeal membrane oxygenation

coding procedures

documentation

HeartMate 3

intracorporeal setup

extracorporeal setup

modifiers

unlisted codes

ECMO management

billing accuracy