Hello, everyone, and welcome to our webcast. I'm Michelle Platt, Revenue Cycles Specialty Coder for MedAxiom. I'm also joined by my colleague, Jolene Bruder. Before we get started, I wanted to go over the control panel. To access the slides for today's presentation, you'll need to click the chat box to access the link. Please do not use the chat box for anything else, especially questions. For questions, you will need to submit them through the Q&A box. As always, we ask that you keep questions on topic and also know that we will answer as many questions as we can during the webcast. We will also compile all of them and provide the answers in the Academy dashboard on our website. The coding CEUs for the AAPC will be available to view and download in the transcription section of your MedAxiom Academy account. We are asking for one to two business days to ensure that they are added. Keep in mind that you do need to individually register and launch the webcast to get credit. You may still listen as a group, but you still need to individually launch the webcast. CEU certificates are also available for BMSC holders. As always, please email Jolene directly to receive those. 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. Finally, this is the CPT disclaimer. All codes from this content are from the American Medical Association CPT. So on our agenda today, we will cover coronary artery bypass grafts, open valve procedures, maze procedures, and other heart procedures and ECMO. Let's get started on my personal favorite, cabbage. In this picture of the heart, we have the right coronary artery and the left main coronary artery. Both of these originate from the root of the aorta. The RCA supplies blood to the right atrium, right ventricle, and the SA node and the AV node. The left coronary artery, the RCA, then descends into smaller branches, including the right posterior descending artery and the acute marginal arteries. The LAD and the left circumflex split off the main coronary artery. Combined, these two arteries supply blood to the left atrium and left ventricle. The LAD is responsible for blood supply to the left atrium and the posterior lateral aspect of the left ventricle, while the LAD supplies blood to the anterior portion of the left ventricle. Branches of these coronary arteries are the obtuse marginals, the diagonals, and the septal perforators. So here we have a breakdown of each artery and their branches. So for the LAD, we have the diagonal branches and the septal perforators. The left circumflex, we have the obtuse marginals, and the right coronary artery, we have the SA node, the AV node, the acute marginal, the posterior lateral, the posterior diagonal, and the right ventricle branch. But CABGES can be done with only veins. In order to code these properly, you need to count the distal anastomosis. For veins only, meaning no arteries were utilized as graphs, you would use the codes which are split out by how many veins. So 33510 is one vein, and 33511 is two veins, and so on and so forth. As you can see, 33515 is not actually used and skips to 33516, which is six or more veins, and that is the highest it goes. So if they do an eight vein bypass, you would still only code 33516 for six or more veins. If the surgeon is only performing an arterial bypass, you code by the distal anastomosis of those graphs. These are billed by one graph through four or more. If the surgeon is performing a combination arterial and venous CABGES, then you choose two codes, again by the distal anastomosis for how many arterial graphs are used and by how many venous graphs were used. So if it's artery only, you choose the correct code from 33533 through 33536. If they are doing a combo, then you choose one code from the artery section and one code from the venous section. Here we have a couple of bypass graphs. In the picture on the left, it shows a result of a four vessel bypass. To determine the correct amount of graphs and what codes we use, you need to know what types of graphs and where they are distally sewn. So here we have the LEMA was used and three staphinous veins were used. Here we can see the LEMA was sewn to the LAD and then three staphinous vein graphs. One was sewn to the left circumflex, one sewn to a branch of the diagonal, and one to the right coronary artery. In the picture on the right, we have the right internal thoracic artery sewn to the right posterior descending artery. Then the graft is connected to the LAD branch and a branch off the LAD. So even though there were only two graphs that were used, they were placed in three different areas, making this a three vessel bypass. The vessels that are commonly used to make the graphs are the internal thoracic and the LEMA and REMA arteries. Procurement of these are included in the graph codes. If they use the radial artery, there is a code for removing that vessel. The great staphinous vein is also used and less done endoscopically. Oh, I'm sorry, is also included in less done endoscopically. The top picture, they show removing of the radial artery from the arm and then they use it in the bypass, which is shown in this bottom picture here. So there's the radial artery that they used for bypass. The staphinous vein is the most common used in cabbage. Please do not ever use ligation codes 37700 through 37735 for the removal of this vein. Here are some things to remember when grafting. When only a vein bypass is done, procurement of the staphinous vein is included in the work of codes 33510 through 33516. Procurement of the LEMA and REMA is included in the work of codes 33533 through 33536. To report endoscopic harvesting of the vein, you would use code 33508. 33509 is new for this year and would be used for endoscopic harvest of an upper extremity artery. Keep in mind that 33508 and 33509 bundle with the arterial graft codes 33533 through 33536, but a 59 or X modifier is allowed on the endoscopic codes. 33572 is reported for harvesting of the femoral popliteal vein and for open harvesting codes 35500 would be used for open harvesting of an upper extremity vein and 35600 would be used for open harvesting of an upper extremity artery. So the use of this code is for reoperation of either a valve procedure or a cabbage. For example, if the patient had a prior valve procedure at least 30 days prior to the cabbage, you would report this code or vice versa. It's also used for a prior valve and a current valve procedure and a prior cabbage and current cabbage. Note this is also used with bental procedure. Also, if the patient had a prior sternotomy and is now having a cabbage, a valve can be cabbage or valve, you can also use this code as well. These codes are also new for this year. They describe the surgical exclusion of the left atrial appendage. These procedures are performed in patients with atrial fibrillation. The LAA is the most common site for thrombus, blood clots in the LAA where clots can form and travel outside the heart to the brain, resulting in a stroke. LAA can be performed as a standalone procedure reported with code 33267 via sternotomy or thoracotomy. 33267 would not be coded in conjunction with any other sternotomy or thoracotomy procedure during the same session. 33268 is an add-on code to be used at the same time of another sternotomy or thoracotomy procedure. If done thoroscopic, use code 33269. If done thoroscopic, use code 33269. Keep in mind that all three of these codes should not be reported with any mitral valve repair or replacement procedure or any maze procedure. If the surgeon performs an endarterectomy of the left anterior descending or the left circumflex or right coronary artery, you will use this code. If they perform the endarterectomy in all three arteries, then you would list this code three times. It can be reported for each artery. There is no code for an endarterectomy of the aorta, so if the surgeon performs that, it is reported with an unlisted code 33999. I also wanted to point out some codes of procedures that are almost always performed with a CABG. 33542 myocardial resection and 33545 repair of post-infarct ventricular septal defect. So this procedure is to treat congestive heart failure subsequent to a myocardial infarction that has caused scarring or aneurysm of the left ventricle, resulting in a large, enlarged, rounded heart. SVR restores the heart to a more normal size and shape, thereby involving or improving function. Cardiopulmonary bypass is initiated. The ventricle is collapsed. A small incision is made in the bottom of the left ventricle through the scar tissue. The heart is opened and the area between the scar and the good heart muscle is identified. Using a plastic model of the heart selected based on the body surface of the patient, the surgeon reshapes the heart. Rather than closing the defect, the surgeon sutures a patch over the defect to restore the normal spherical shape of the heart. For the use of epiaortic ultrasound, the surgeon must document the findings of the aorta in order to build this code. It's not to be used for harvesting of the grafts or used as a mapping tool. It's only built when it's used to aid cannulation of the cardiopulmonary bypass, a cross clamp evaluation, or to identify a dissection of the aorta. So let's go over some case examples. So for my case one, we have a diagnosis of coronary artery disease and diabetes. Their operation is going to be a four-vessel off-pump coronary artery bypass graft, endoscopy vein harvest, epiaortic ultrasound, TEE, ligation of the left atrial appendage. So this is a pleasant 73-year-old with a history of diabetes who presents with symptoms of mild heartburn, indigestion, and chest pain. The patient was evaluated by her cardiologist. Subsequent evaluation included a left heart cath that demonstrated significant three-vessel coronary artery disease. And so the patient was referred for coronary artery bypass. So the patient was taken to the operating room. A transesophageal echo was placed to monitor the patient's cardiac function. And I personally reviewed and independently interpreted the intraoperative echo findings. Endoscopic staphinous vein harvesting of the lower extremity was performed. The vein conduit was of moderate good quality. A media sternotomy incision was performed. The left internal mammary artery was harvested in a skeletonized fashion. It was a small vessel but had good flow and good conduit. Epiaortic ultrasound demonstrated mild atherosclerotic disease in the aorta, grade 2. We ligated the left atrial appendage using a 35-millimeter clip device. The LAD was identified in its portion. In situ LEMA was adenostomosed to the LAD using proline suture. The posterior descending artery was identified. A vein graft was sewn to the posterior descending vessel using proline suture. The first diagonal branch was identified. A vein graft was sewn to this vessel using proline suture. The second branch and the obtuse marginal branches were identified. They were too small to bypass. The third diagonal branch was identified. A vein graft was sewn to this vessel using proline suture. A side biting clamp was placed on the proximal ascending aorta. Two separate proximal anastomosis were performed individually to the ascending aorta for the two vein grafts to the first diagonal branch and the posterior descending artery. Because the vein graft of the third diagonal branch was not long enough to reach the ascending aorta, I performed a proximal anastomosis end-to-side to the left vein to the first diagonal branch using running proline suture. This was done in a surgical Y configuration. The vein grafts were all de-aired. For our final answer, we have a 33533 for one arterial bypass graft, 33519 for three venous grafts, 33508 with a 59 modifier for the endoscopic vein harvest, 76998, 2659 for the epiaortic ultrasound, and a 9331426 for the TEE. I just want you to note that the LAA was not coded as medical necessity was not met in this case. I also wanted to point out that 33508 bundles with the arterial graft codes and 76998 bundles with the venous graft codes, but a 59 or X modifier is allowed on both of these codes. So for our case number two, we have severe multivessal coronary artery disease. They have angina, diastolic heart failure, history of AFib, previous percutaneous coronary intervention, and then remote history tobacco abuse. So our procedure, we're going to have a four vessel coronary artery bypass, lower extremity endoscopic vein harvest, a TEE, and then the left atrial appendage ligation. So this is a 58 year old who presents with findings of multivessal coronary artery disease, AFib, and angina. The patient was brought to the operating room. The patient was prepped, positioned, and draped in the usual fashion. Next, careful media sternotomy was performed. The left internal mammary artery was harvested from the posterior chest wall. Simultaneously, endoscopic vein was taken from the lower extremity on the left side, utilizing the endoscopic harvesting system. Full cardiopulmonary bypass was initiated. Aortic cross clamp was gently applied. First vessel grafted was the high diagonal ramus type vessel, grafted in a side to side fashion with a running proline. The second vein graft was then grafted to the mid-obtuse marginal. After completing these two distal touchdowns, we grafted the PDA with running proline. This vein graft was brought around the acute marginal of the heart, anastomose to the anterior lateral wall of the aorta. Finally, the lemur was anastomosed to the LAD with a nice target in the midpoint with proline suture. The aortic root was carefully de-aired and the patient was easily weaned from cardiopulmonary bypass. So given that the patient had intermittent atrial fib, the left atrial appendage was ligated with 35 millimeter clip, which was placed at the base and confirmed on TEE. So TEE images obtained and the probe was placed by the anesthesiologist, documenting overall reasonable ventricular function, and then I personally reviewed it independently and interpreted the TEE findings. So our final answers on this one are 33533 for one arterial venous graft, arterial bypass graft, I'm sorry, I'm reading ahead of myself, 33519 for three venous grafts, 3350859 for the endoscopic vein harvest, 33268 for the LAA ligation, and 93314 for the TEE, 26 for the TEE. And then the 33508 with the 59 or X modifier due to the bundling with the 33533. Okay, I'll turn this over to Jolene now. So we're going to switch screens real quick here. Thank you so much, Michelle, that was great. All right, so we're going to move on now and we're going to discuss the heart valves. So for some of you, this may be a refresher, but I like to go through the anatomy so that our newer coders understand these procedures better. Sometimes the picture paints a thousand words. So on this one, and I think I've said this before in a webcast, but I always liked it. Those of you that are old enough to remember Happy Days, Patsy had to do a speech one time. And you can go out on YouTube and actually watch Patsy's speech on blood flow through the heart and the body, and it's kind of fun. But anyway, so what happens here is the oxygen poor blood comes through the vena cava. It enters the heart to the right atrium. Then the tricuspid valve will contract, and it pushes that blood down here into the right ventricle. Then the pulmonary valve, well, the right ventricle will then contract, and then pushes the blood through the pulmonary valve, and it goes out through the pulmonary arteries to the lungs. Once it's in the lungs, then it picks up oxygen, and it returns to the heart through the pulmonary veins. So then that comes in through the left atrium. The mitral valve or the left atrium will contract, and then the mitral valve will push the blood down into the left ventricle. The left ventricle contracts and then pushes the blood through the aortic valve, which then sends the blood through the aorta, and that's how it gets out to the rest of the body. So as you can see, if any of these things are not functioning well, then it's going to, you know, it throws the whole system off. So because, you know, as your heart beats, that's when all those contractions are happening and pushing the blood around the heart and out to the body. So if there's any disruption in that, then that causes issues. So again, just to show the picture, this is our aortic valve here. The pulmonary valve is up here, tricuspid is here, and mitral is right here. So again, these are the four valves we're going to talk about. Now, I do want to point out before I actually get into the coding for these, we're not going to cover TAVRs, TEMVRs, all of that stuff that is all part of structural heart. And although surgeons get involved in those procedures, they're mainly ran by the cardiologist. So TAVRs themselves do require a CT surgeon per the Medicare NCB, but we're not covering that here. So we're basically talking about the patient has to go to the surgeon, they're going to have their chest cut open, and they're going to work on the valves. But anyway, so let's talk a little more about the function of the aortic valve. So again, it's between the aorta and the left ventricle. And then once that ventricle contracts, it pushes that blood into the aorta, as I showed in the little diagram of the blood flow. So these two pictures, they'll show you, we have a nice, healthy, open valve, and it's really wide open. It's a tricuspid valve. Sometimes the aortic valve will only have two cusps, which is then called a bicuspid, but that is actually a congenital problem, but it's usually not major to where they have to do anything unless the patient starts developing problems. So then once that valve is closed, as you can see, it's nice and tight, and it stops the blood flow. Well, once these start stenosing, then you can see there's a buildup of plaque around those openings. Well, now your valve's not opening as wide, so therefore not as much blood's coming through. So when that happens, that makes the heart work harder. Also, when it closes, it doesn't fully close, so then that creates problems as well. So again, that stenosis is from plaque buildup, and it does cause the heart to work harder. Any abnormality with the valves can cause the heart to function not as well as it should. So the actual mitral valve, the function of it, this is a true bicuspid valve, and again, it is to push the blood from the left atrium down into the left ventricle. So that's where it's located, right here, and I'll show you. This is normal, and then this can be regurgitation, which we'll talk about here in the next slide a little more. So what happens with regurgitation is that that valve doesn't close properly. So the blood actually will back up and go back up into the left atrium, and it's all supposed to be down here in the ventricle. So as that's coming back, now it's pulling with blood that's already coming in for the next cycle, and so normally you can't, it doesn't look this clear on the picture of when they're actually looking at the heart, but as you can see, that blood's backing up. It's not flowing like it's supposed to. Stenosis, basically the same thing. You have that buildup of plaque. So what happens here, though, is this is not opening enough to allow that left ventricle to fill properly. So this is a normal heart, and that's a normal functioning valve, and the blood flows easily into the left ventricle, and then on this side, once it starts narrowing, you're not getting as much blood flow. Again, mitral stenosis itself is mainly a result of rheumatic fever. However, it doesn't have to be, but at the same time, rheumatic fever is actually rare for the U.S. population and other developed countries. Rheumatic fever often results from untreated strep throat or scarlet fever, but with more and more people coming from other countries that aren't as developed as the United States and probably most of Europe, then they might've had that rheumatic fever, so now they have this condition. So it's important that if, not to get into the whole diagnosis thing, because that's its own little controversy, but if the patient actually has rheumatic valve disease, it's important for your physicians to actually clearly document that. If it's not, then the default, if you don't already have a policy in place, the default is for the ICD-10 code, you have to code the rheumatic if you have multiple valve disease problems, and that's clearly spelled out in the guidelines, and for more information on that, you can go look at your ICD-10 guidelines. All right, so the tricuspid valve, again, this is located down the right side of the heart. It's also known as the right atrial ventricular valve. It's located in the upper portion, and it's in between the right ventricle and the right atrium, and again, its function is to prevent any backflow, so here's that regurgitation again. You don't want the blood to go backwards through the valve. It should all flow nice and smooth the way it's supposed to. Actually, regurgitation in the tricuspid area and insufficiency, people don't necessarily know they even have this problem. A lot of times it shows up as, if you can see the pulses in the veins of someone's neck, that's usually a good indication that they might have that tricuspid regurgitation. Sometimes they'll have shortness of breath with activity or when they lie down. They could also end up with an enlarged liver or swelling in the abdomen, legs, feet, or ankles, so it's important to pay attention if you develop any of those conditions, not saying that that's automatically tricuspid regurgitation, but it's certainly nothing that you want to ignore. All right, and finally, we're gonna talk about the pulmonary valve just a little bit. It does have three cusps, and it allows blood to pass from the right ventricle to the pulmonary arteries. There isn't really a lot of work done in that area. Some of this, you'll have congenital issues with it, but cardiac surgeons do at times replace these valves, but it's rare, so we're not gonna spend a lot of time on that. Again, same thing with the stenosis. You have that narrowing of the opening, and it doesn't open as well as it should. The heart can enlarge from this condition because you don't have enough blood flow, and this also increases hypertension to the right side of the heart, so if you see right-sided hypertension, that's what they're talking about. Usually it's a problem with that pulmonary valve. Oh. With regurgitation, again, it's not closing properly, so the blood flows backwards. So how do we fix this stuff? Well, again, we're gonna talk about opening the patient up and fixing these, so this is, we're not doing that less invasive. We're actually doing a full sternotomy. Thoracotomy sometime. So a lot of times, depending on the severity, sometimes these can be repaired versus replaced, and of course, they always try to do what is the easiest and best for the patient. If it's worn out to the point that it needs replaced, then obviously they need to replace it, but if they can avoid doing that, they try to. So there are two separate codes for aorta valvoplasty or valvuloplasty. These are open. They are perform a cardiopulmonary bypass. So these two codes are basically split out by whether it was a simple repair or a complex. It's important your physicians tell you. Again, and I've stressed this since I've been a member of MedAxiom, since I've worked for MedAxiom, it is very important to develop those relationships with your physicians so that you can go and ask them if something is not clear, because otherwise it's a guessing game, and we're not supposed to code by guessing. We need real clear answers. If you don't give that feedback to the provider, you can't expect them to automatically know that they're not giving you enough information. So, and you can usually find at least one surgeon that will be friendly and talk to you. And I know that they can be alpha personalities for sure, but they are human. So just reach out and develop those. And sometimes you may need to go through your administration, whatever works. But obviously in order to be a good surgery coder, you have to have good communication with those surgeons. All right. So in this group of codes, they can, the 33404 is used if they happen to place an apical aortic conduit. I haven't seen that done a lot. We also have the replacement codes. So there's this group, which we'll get into more in depth. And then there's also replacement with annulus enlargement of the non-coronary sinus. And then finally, then we also have resection with myectomy or aortoplasties performed. And again, we'll go into this in a little more detail. So 33405 is your most common aortic valve replacement code. Notice the code does specify that it's open. This is for a stented valve. Now you're probably not going to see that wording, but just so you know, we're not talking stentless and we're not talking a homograph valve. We're talking a stented valve. For 33406, this is actually an allograft and it's normally created freehand in the OR work. So I had asked one of my surgeons years ago, I'm like, what is this thing? And he explained to me, he goes, basically they take tissue and they just whip it up and make a little freehand valve out of it. It's also not done that often, but that's what it is. And it is used with allograft material. And then finally we have aortic valve replacement with a stentless valve. So again, if you're unsure what's performed, then you need to have these discussions with your provider. Now the 33440, this is actually a combination of the Ross and Kono procedures. Now we still have the individual codes for them. You know, if they're only doing a Kono or if they're only doing a Ross, but if they're doing a combination of both, then this is your animal. It is a replacement of the aortic valve along with transventricular aortic annulus enlargement. The procedure not only replaces the valve, but it also widens the ventricular sectum. It is done for treatment of aortic stenosis, ventricular outflow stenosis. Note in your book, it is out of sequence from the others. And then you do not report this code with the open aortic valve procedure, the other ones. All these codes here do not report the 33440 with any of these codes. It also is not reportable with pulmonary valve replacement and the pulmonary atresia with ventricular septal defects either. Okay, I just, a question popped up. I'm gonna go ahead and talk about it. So as far as ICD-10 coding, we're not focusing on that today, but your guidelines state if the patient has multiple disease, valve disease, the ICD-10 guidelines state you must use the rheumatic valve codes. Now, some practices put the policy in that if we don't specifically say rheumatic, then it's not rheumatic. It just depends on what your practice wants to do. I cannot legally advise you on what you should or should not do. I'm just telling you, if there is a policy in place, then you need to follow your practice's policy because those policies usually go through a lawyer. But it is not, even though if rheumatic, and I know this sounds crazy, none of us agree with this, but it's just something that hasn't caught up. If the patient is not specified as having rheumatic valve disease, now we're talking multiple. If your doctor dictates patient has aortic valve stenosis, then by all means, use the aortic valve stenosis codes. If they say patient has rheumatic aortic valve stenosis, then you need to use the I codes. If they have multiple valve disease, and I apologize, my phone shouldn't be ringing. Anyway, if they have multiple valve disease and it is not specific that it is rheumatic or not, the guidelines tell you that the default for this is you have to pick rheumatic, which would be your I codes. So I know it goes against everything we're ever taught because now the question comes up, are we assigning people rheumatic disease when we don't know? So again, it's very important to have those conversations with your physicians because this could be solved real easy by all they have to say is non-rheumatic aortic stenosis, non-rheumatic mitral valve stenosis. We have three valve disease that has nothing to do with rheumatic fever, something to that effect. If they're very clear, it makes it easier on you. All right. Okay, so our other aortic valve procedures that happen, 33411 is probably, it's pretty popular as well as the 33405. And this was because sometimes they have to do that enlargement of the aortic annulus. The Kono procedure is actually for transventricular aortic annulus enlargement. Ross procedure is complicated where they use the pulmonary artery and actually attach it to the aortic position. So now you're moving an artery into the position of a valve and they remove that valve. That's the Ross procedure. For 33414, we have the left ventricular outflow track by patch enlargement. And that's performed when there is an obstruction in the ventricular outflow track. Aortic valve is replaced and the left ventricular outflow track is reconstructed. You can also run into 33415, which is for subvalvular aortic stenosis. So it's below the valve. That's what subvalvular stenosis is. And then they can also do a ventricular myotomy and that can be performed as well as doing an aortoplasty with a gusset. So that's the description of these codes. Again, they're probably not that common other than the 33411. I do see 33415 used as well, but they're not as common. All right, so now we're gonna move on to mitral valve tricuspid valve. So with the mitral valve procedures, most common would be obviously a repair or a replacement. I wanna point this out too, and this is for all valves. If they attempt to repair and the repair doesn't work and they have to go with a replacement, you do not code both procedures. You only code what was successful. Now, that being said, if they spent several hours and they document this well, and your carrier plays along with a modifier 22, then you can add a modifier 22 to that replacement code because maybe they spent two or three hours trying to get it to repair and it wouldn't. So then they resorted to that replacement. Again, it all comes down to documentation. If the documentation supports the 22, then by all means, use it. One note on the 22 modifier, and again, you're at your carrier's mercy. Some carriers have no problems paying the extra, but some of them don't. They won't, no matter what, they won't pay. So if you're in that case, I wouldn't necessarily add 22s if you're not successful, because here's the thing. When you place a 22 modifier on a procedure, it will sit for a while while they adjudicate it. So it might be six months later when you get an answer. That entire claim is held up until that 22 is resolved. So that can slow down money coming through your practice. If you're successful though, then by all means, some of these procedures is definitely worth the wait for the extra money. But if you're not being paid, then why hold up your claim? So it's kind of one of those, depends on your carrier and depends on if you're successful. I know I'm kind of laughing to myself because I had a physician I worked for that he would call me with charges and he would tell me, hey, put that pain in the butt modifier on this patient. So anyway, so if it's a pain in the butt, then you might need to do the 22. All right, let's get back to what we're talking about here though. So when you're doing mitral valvuloplasty, the procedure 33420 means the pericardium is open, incision is made within that left atrial appendage. That's why we do not code that LAA separately with the mitral valve because they're already taking care of it. They can use a tub's dilator or the physician can use his glove finger or her glove finger. And it's introduced into the left ventricle by way of the apex. It opens in the valve. Calcium deposits can be removed from the annulus and leaflets with what's called a bone nibbler. And then upon completion of that valvotomy, the dilator or the physician's finger is removed and then the incisions are sutured closed. I don't see that happen on a lot either. For 33422, left atrium is open from the right side. Mitral valve is exposed. If there's any scar tissue, that is anything that's between those lateral ends of the valve and the leaflets, that's all excised and divided. In 33425, the left atrium is open and redundant mitral valve tissue is excised. And then the defects of those leaflets are closed with sutures. For 33426, this is probably, these next two are most common for mitral valve repair. They will place a prosthetic ring. For 33427, so the CPT code states 33427 is extensive repair of that mitral valve. Well, what does that mean? You know, and the extensive is subjective. So the STS, which is a society of thoracic surgeons put out a long time ago, anything other than a ring is considered extensive. But keep in mind, you don't have to use a ring. So what you're going to be looking for then on whether or not it's extensive repair, are they transferring those cords from the posterior leaflet to the anterior leaflet? If they're opening it up, they're placing a ring and they're dropping it back in, that's your simple three, three, four, two, six. So once they start moving cords around and transferring that and messing a lot with the leaflets, then you're looking at something that's more extensive. And then of course our final code is replacement of that mitral valve. And that's what the three, three, four, three, zero. For tricuspid, we have valvectomies. And again, those can be done, that can be done, or you can do the valvoplasty with or without a ring. And then also we have replacement. Again, if that repair is attempted, but not completed and you have to go with, you have to go with the replacement, again, you can try that 22. For patients that have the Epstein anomaly or Epstein, depending on what part of the country you come from as to how you pronounce that, three, three, four, six, eight. So that Epstein anomaly is where the tricuspid valve annulus is displaced onto the right ventricle. And then the valve leaflets actually become tethered to the wall of the ventricle. And then when that happens, that's actually a congenital condition. So this may or may not be performed by an adult cardiac surgeon, kind of depends on how aggressive your adult cardiac surgeons are. More than likely it will be done by a pediatric or I shouldn't call them pediatric, congenital CT surgeon. So more on valve procedures. When billing for multiple valve procedures, and let's say they're doing a valve and a cabbage, if your carrier requires, please, if they do not, don't worry about it. Do not change anything you're doing here just by based on this webinar. So if your carriers require you to add 51 modifier to multiple procedures, then by all means, please do. Make sure you put that 51 though on the proper CPT code. Do not reduce your primary procedure. So you'll have to look at the RVUs and see which one is actually weighted higher. Like right off the top of my head, I know the aortic valve is higher than a cabbage. So normally you're going to put the 51 modifier on the cabbage code, not the aortic valve code. But if your carriers don't require you to put the 51, then please don't, because if you also put a 51, then it's going to get reduced twice. And you don't want that. Michelle already talked about the 33530, and that is the redo cabbage or valve. So again, keep in mind, these are different now. They do look at the fact that you have, if the patient's already had a previous sternotomy or thoracotomy, and you're going through that incision, that builds up with adhesions. So you can use the 33530 to report that extra work basically is what you're doing. The caveat is you have to now be doing a cabbage or valve. So if they did a cabbage or valve six months ago, and now they're bringing them in and they're going to remove a lung, you cannot use the 33530 for removing that lung. It only can be for a cabbage or valve procedure. All right, and again, I'm not spending a lot of time on the pulmonaries. You've got the valvotomy, which is closed heart or open heart. Open heart does have the cardiopulmonary bypass. You can also replace it. And then you can do these right ventricular resections or outflow track with that gusset. Okay, moving on to maze. So maze procedures, they're actually the open version, so to speak, and I'm being pretty liberal here with the terminology and the amount of work, but they're basically the open version of EP ablations. So they're not done as often anymore with the advancement of EP ablation studies. And those are less obviously invasive when your EP doctors are doing those ablations. They are still done. Primarily, I would say they're more done if they're already doing another heart procedure versus just bringing a patient in for a maze. So normally this is going to be done in conjunction with another heart procedure. Doesn't have to be, but that's probably the more normal version or use of it now. So it is performed to treat atrial fibrillation. It uses a combination of surgical incisions or energy sources. Lesions are created and they'll disrupt that conduction of the atrial form. They also do some pulmonary valve isolation. And again, they can be done standalone, but not as often. They also can be done endoscopically. Now you may or may not see that. Of course, you know, these codes are broke out. So you have your limited endoscopic, extensive endoscopic, limited open, off bypass, on bypass, all that good stuff. But keep in mind, there is a difference between a limited and extensive. Again, if you're unsure, not clear, you have to go back and talk to your physician because the technical terminology that says what makes a maze extensive, it says everything that's done in a limited maze, as well as atrioventricular annulus, they have to do some type of ablation in that area. So if you're not sure, you need to talk to your physician. A lot of times they will tell you, I did an extensive maze. I take their word for it. The ones that I have that relationship with, that I know that, you know, they know what they're talking about. If you're new to it though, have them explain it to you. Limited maze, keep in mind, does not specify whether or not cardiopulmonary bypass is used. So keep that in mind. I cannot tell you how many times I've seen this coded, the 33259, which is the extensive maze, just because the patient was on bypass. That has nothing to do with it. If they're not on bypass and they do an extensive maze, then you're going to use the add-on code 33258, or you'll use that open code or the standalone 33255. Once it's limited, it can be on or off bypass. And then the extensive is determined between whether or not they're on or off bypass on which code. So normally you're going to see some type of, they'll put burn lesions into the areas of the AV area, the atrial ventricular area. Anyway, that's my scoop on the maze. So it's everything that's in the 33257, and then plus they have to do something around that atrial ventricular annulus. So they might be putting lesions around there, but that's what would be considered extensive. Also keep in mind, if they only do a left atrial appendage, that is not a maze. That is its own little left atrial appendage code. Again, you have to meet that medical necessity. If they do the left atrial appendage with a maze, you do not code for that left atrial appendage clip separately. Michelle covered that pretty good in her section. So just keep that in mind. If however, they only do a left atrial appendage procedure that's open, then you would code the 33267. Again, they have to have atrial fib, and that's the requirement. The CPT book spells that out pretty clearly. All right, so we're gonna talk about some other open heart miscellaneous procedures that are also done. So we have pericardiosynthesis, and that can be done with imaging guidance or without. If they do use imaging guidance in the 33016, that's included. For 33017 and 018, they'll do a pericardial draining with insertion of an indwelling catheter. It is done percutaneously. It does include fluoroscopy and or ultrasound guidance when performed. 33017 is for ages six and older without a congenital anomaly. And 33018 is for birth through five years of age. Or if it is a congenital anomaly, it doesn't matter how old they are, you would use the 33018. We also have pericardial drainage with insertion of an indwelling cath using CT guidance. Sometimes, a lot of times your cardiologist will probably do these, but surgeons can. For 33020, we have pericardiotomy for removal of clot or form body. Notice that is considered a primary procedure. 33025 is creation of that pericardial window, or sometimes you'll see it as a resection for drainage. This can also be done by vats. So if it's done through that video-assisted thoroscopic, that's what VAT stands for, video-assisted thoroscopic procedure. If they do it that way and not open, be sure you use your VATs codes. However, if they do it by open, then do not code this one because you're severely under-reporting that procedure. We also have 33030 and 33031. Which is your pericardiectomy subtotal or complete. And that is with or without cardiopulmonary bypass. You choose your code based on whether or not the patient was on bypass. And then for 33050, we have resection of a pericardial cyst or tumor. These are for neoplasms or transmyocardial revascularization. That's what TMRs are, laser, sorry. Transmyocardial laser revascularization is also known as a TMR. And we have excision of intracardiac tumor is reported with 33120. Resection of external. So one is within the heart and the other one is outside of the heart. So make sure that you know where they're at. With the laser revascularization, that is done, can be done by thoracotomy. It is a separate procedure. If they do it in conjunction with another cardiac procedure, then you use the add-on code 33141. Okay, this group of codes are procedures for heart and great vessels. Now note, these are repairs for cardiac wound. Well, 33300 and 33305 are direct repairs of cardiac wound. 33310 and 33315 is for removal of a foreign body or an atrial or ventricular thrombus. Keep in mind, these are not for congenital diseases, nor are they for any wound created by surgery. These are trauma, these are done for trauma. So a lot of times you'll see this, stabbings, gunshot wounds, sometimes car accidents, if it's severe enough. And that's when you're gonna use this group of codes. Do not use these group of codes for congenital or acquired diseases of the heart. One thing too, with the last set here, this last group, they can be inserting a graft for the aorta or great vessel. One again is with cardiopulmonary bypass. The other one is with a shunt. So these are some miscellaneous items that can happen with these procedures. And this is mainly mechanical circulatory support, otherwise known as a balloon pump. There's a series of these codes. They can be inserted or removed percutaneously. They can be done by open means. So they might have to cut into the artery to do it. Again, it's very important that your physicians tell you how they did this. You can't guess. Sometimes keep in mind too, so especially like with a CABG, if a patient started out in a cardiac cath, they went ahead and placed the pump, cardiologist does, cath doesn't work, they're either trying to do the intervention or they decide, hey, we can't do that intervention. They need to do bypass. We're taking them straight to the OR or maybe they take them back to their ICU and they leave the pump in until the surgeon can get to them. Sometimes they're placed by somebody else. And mainly that would be a cardiologist. If that's done, then you don't code for it. If they already come into the OR with a balloon pump, you don't code for that balloon pump. What you can code for though, is if the patient stabilizes after their surgery. And once that patient stabilizes after their surgery and they remove it, then you can code for the removal. If the CT surgeon performs the removal. Again, it's important that they document how they do it. I'm looking at the question on the 3, 3, 3, 0, 0. Okay, here's the thing. So yes, so the question is the 3, 3, 3, 0, 0 has an ICD-10 code of I-9752. Accidental puncture or laceration of the circulatory system or structure during other procedure. Isn't that a surgical wound? Yes, it is. However, who caused that? If the surgeon caused their own wound, you cannot code for it. If however, they were having something else done and there was an accidental puncture or laceration and they have to call in a CT surgeon to fix that, then in that case, yes. But if my cardiac surgeon is doing a coronary artery bypass and he causes a puncture or laceration of something to the circulatory system, he has to fix it. He caused it and you don't get to code for that. So keep that in mind. Sorry, I wasn't completely clear on that on that other slide but normally those are gonna be trauma codes that are done. You can, there is some exception to that. But again, it has to be well-documented and it depends on who did it. All right, so let's move on to ECMO. Now ECMO poses its own issues sometimes. So we have, so ECMO basically provides cardiac and respiratory support to the heart and lungs. It does continuously pump blood out of the body, goes into an oxygenator and then it adds oxygen, removes carbon dioxide and blood's warm and then it's returned. You can have a veno-arterial or a veno-venous. Now, sometimes these are placed, so, okay, here's the thing. We don't normally, when a patient's on cardiopulmonary bypass, you don't normally cart that machine off with them if they still need help. So that's when you might place an ECMO. ECMOs are replaced for a variety of reasons. That's just one scenario. For a veno-arterial ECMO, you have to have two cannulas. One's placed in the large vein and one is placed in the large artery. It supports not only the heart, but also the lungs. This does require two cannulas. For veno-venous, you could have one or two cannulas, but these are only placed in the vein and they're only support the lungs. So keep that in mind. So more on ECMO. Again, these are, these services, the 33946 through 33949, this is managing that machine. This is initiation management, or actually, wait a minute. These services manage a machine, not the patient. If you need to manage the patient, then you use appropriate E&M codes. However, if this is a CT surgeon, he better well document if this patient's on a global as to why that E&M would be separate. Normally, I would say your cardiologist will manage the machine and then that patient, not always though. So just keep in mind when they're documenting that they're doing that management on the ECMO, are they managing the machine or are they managing the patient? So for the insertion codes, there is a very nice chart in the CPT book that shows all the different scenarios for ECMO. You may want to look it over, but the codes are split out by approach. So did we do a percutaneous insertion? Did we do open or thoracotomy? Open would be cutting into the arterial. Thoracotomy means you're cutting open into the chest. They also split out then by how old or how young the patient is. So from birth to five years, which most of your CT surgeons are not going to be involved in that, that would be your congenital heart surgeons. CT surgeons and adult are mainly gonna live in the 33952, 33954, or 33956 area. Now, when you're doing, any insertion, you do not also code any management of the ECMO. That's not separately billed. That would be done the next day, not the same day of insertion. That also goes for any reposition. The reposition codes, again, are split out by age and then whether or not they're percutaneous, open or by thoracotomy. They do have to be a separate session, not a separate day, but they do have to be separate session from that initial insertion. So if they did their CABG or their valve and they put the patient on ECMO and they're like, yeah, we don't like how that's working. So they reposition those cannulas. That's, you only code the insertion. Now, they insert it and then they take them back to the ICU or wherever they're going, more than likely ICU. And then they bring them back to the OR and like, hey, this isn't working. We need to reposition these. Then by all means, you're at a different session. Now you can bill for the reposition. So always keep that in mind. Oh, one other question that popped in here. I'm trying to answer these as we go because sometimes we run out of time. This says, can a PA or NP remove the intra-aortic balloon device after surgery or would this be included? Removal of the intra-aortic balloon pump is separately codable. As far as who can remove it, that depends on the license of your state for your physician assistant or your NP. It does not require a doctor as long as that your state allows it to be a non-physician. So let me put it that way. So if your state allows your PA to do it, then by all means you can code that with them. But if not, then no, it has to be the physician. So again, that's a question that, you know, that's more of a legal question and I can't answer that. It just depends on your state. All right, decannulation, so removal of the ECMO, again, this is split out by approach and age. You also do not code this as the same session. So if they start to put the patient on ECMO and decide they don't need the ECMO and they remove it at the same session, you do not code for both, have it only code for the insertion. And then if they bring them back later that day and remove it, that's fine. Or if they do it the next day, then you can code for it, not at the same session. So some other codes that are used with ECMO. So this is interesting and this comes up a lot too. So back, ECMO has been around for a long time. So back in the day, we had the 33987, which is the chimney graft, and that helps facilitate that arterial perfusion. So if you have a patient that might have a more stenosed artery and they put in a chimney graft to help run that cannula through, then you use that in conjunction with your ECMO. Now along comes the 34716, the 34714, the 34833, those are all add-on codes that are normally done with EVAR, TVAR, FEVAR, but they can also be used in conjunction with placing a patient on bypass. If you use a conduit, those are the conduit codes. Those codes are for bypass. This code is for ECMO. So please don't confuse the two. I see that happen as well. Don't code your axillary artery with a graft conduit if they're using it for ECMO. Use your chimney graft code for that. Then we also have, they can also insert a left heart vent or remove that left heart vent. So again, this is an initiation and daily management. These are not reported the same day. This is the day you place the ECMO. This is everything after that, the next day and so on and so forth. You do not report these the same day. I don't even care what session. Initiation is done on the first day. These are done after. These are performed by the physician normally who inserts the ECMO. Not always, but normally that would be the flow of work. And so a lot of times a cardiologist will take this over. They don't have to. It just depends on what your cardiac surgeons and your cardiologists have worked out amongst themselves. Again, your daily management, well, they're all split out on what type of ECMO did we put in. Did we put in a Veno-Veno or did we put in a Veno-Arterial? So make sure you're picking the right management or initiation code. Keep in mind, you can still, these don't have globals. You can still also bill E&M code. You'll probably need a 25, but the E&M code is managing the patient. This was managing the machine. So these are the codes I was talking about. These are to aid in cardiopulmonary bypass, not ECMO. These are these conduit codes. So keep those in mind. Those can also be separately billed. Again, a lot of times you'll see this with the EVAR, FEVAR, TVAR, but you don't have to. Sometimes they will be used with CABG or a valve or another heart procedure. I've even seen it if they put the patient on bypass with a lung procedure. So it's just keep in mind what you're using it for. The book does have extensive lists of what these add on to. And they do require one other thought. They do require a conduit. This was not cut down. So please don't get that confused either. It involves a cut down, but this was not cut down only. They actually have to have that conduit. The cut down only codes are only billed with EVAR, TVAR, FEVAR. So some other miscellaneous procedures that are done. We have chest exploration for post-op hemorrhage, thrombus, or infection. That's the only reason you can use this code. If you do not have one of those three conditions, you do not use this code. If the patient is within a 90 day global, then you need to report this with a 78 modifier. Now keep in mind, and I know this happens, keep in mind some of these people will, they might be in their ICU and for whatever reason they start bleeding profusely from their chest, they might not have time to take them to the OR. So they'll do it there at bedside. As long as that is well documented that we didn't have time to take them to the OR, then that is fine. You can still build this code. You can still use the 78 modifier. But it has to be clearly documented that it was an emergent situation. All right. We also have code 21750. This can be standalone. This could happen months later, or it can happen, you know, sometimes here's the other situation. So sometimes for whatever reason, they decide to leave that patient open. And they, you know, while I'm talking about that too, if they have to leave the patient open, do not reduce those heart procedures with a 52 modifier, just because they didn't close the patient up. When you use a 52, you're reducing that procedure by 50%. That is way too big of a reduction. That's not, you know, granted, we open somebody, we have to close them back up. I understand that. But if they have to leave them open, and the plan is to bring them back a week later, two or three days later, and then they close that, then you go ahead and bill for the 21750. And instead of using a 78, you would use a 58, because that's planned. If however, the sternum separates during that 90 day global, and they have to take them back to the OR and put it all back together, then you use a 78. So make sure you know what your scenario is, you know, were they left open and for plan on closing later, or did the incision itself just come apart, and they have to bring them back. If they're out of the 90 day global, you don't need to worry about the 78, 58 or any of that. We also have code 21627 that is done and that's for debridement. Note, you do have to actually do, I guess it's debridement. Nicole always yells at me about that. Hey, I'm from the Midwest, what can I say? So the debridement on the median sternotomy separation has to have, or I'm sorry, I'm just the sternal debridement. They have to do debrid the bone itself, it has to go down to the bone. If it's surface, then you have to look at your wound incision and drainage closure or your incision and your open wound, those things, those surface skin codes. The debridement itself for 21627 does have to have involved the bone. On the 21750, you may or may not have debridement. And then finally, again, Michelle had an excellent example of the TEE when that is also allowed to be billed. Keep in mind, there has to be a separate paragraph. We actually prefer a separate report, but that's not, it's not required, it would be ideal. However, make sure your surgeon has made this agreement with anesthesiology and or cardiology, depending on who likes to do the interps, that that surgeon is going to perform that interpretation because you can't both bill for it, only one gets to bill for it. So if your cardiologist places the probe or the anesthesiologist places the probe, then they're going to bill for that. And your physician is going to bill for the interp and the report and the energy. So make sure you know what those agreements are. Do not just automatically code it. There has to be, you know, something in line. It's kind of up to the surgeon. Some places do it, some don't, some like to do it, some don't. So, you know, when in Rome, you got to do what the Romans do, but you also will need that 26 modifier because, you know, this is being done in the, in the facility itself. So in the hospital, when we're doing this with a, with a surgery, I'm not saying TEEs can only be done in the hospital with, you know, or whatever, don't box me in there. I'm talking about with, with an actual surgery. Okay. So let's get to our case examples. This is the exciting part, right? So for case example, number three, I have aortic and mitral regurgitation. I did not list ICD-10 codes. And again, we're, well, we're just not going to go down that road today. We've talked about it enough. All right. This is all the information I have. So we have a reduced sternotomy, aortic valve replacement using a 25 millimeter bioprosthetic valve and mitral valve replacement using a 29 magnet ease bioprosthetic valve, as well as veno arterial, that's what that VA stands for, ECMO. And they also place an aortic balloon pump in the left femoral artery. So I'm, I'm dropping down here, remember lines, swan gans, art lines, all of that stuff is included in your global surgery package. All right. Let's see. Patient was positioned, prepped and draped in standard surgical fashion, followed by routine timeout. They did an incision over the sternum. And there was a previous incision. Once the sternal wires were identified, sternal wires were cut, followed by opening of the sternum. So we know we have a redo here. They had to use cut through with a saw. Sternal wires were removed, followed by completion of the sternotomy, followed by dissection around the right to left portions of the sternum to free it up. Do not code removing of that hardware for this. That's included in the 33530. So that would be our code for the reading. Okay. So I'm not getting into all that. You can go back and read these at your leisure. An aortotomy was then performed by direct visualization of the right and left coronary ostia and cardioplasia was administered, incomplete arrest of the heart, further dissection was performed to visualize that aortic valve. The aortic valve was then excised, followed by placement of a plegated valve suture along the annulus, and additional cardioplasia was given during this time and placement of the valve. The valve was sized to a 25 millimeter magnet ease bioprosthetic valve. Patient's BSA at the time was 2.3. Once the valve was sewn into place and was re-approximated using proline in a continuous fashion, 33405 is your code, followed by administration of the hot shot, they weaned down on cardiopulmonary bypass. However, at that time, the ejection fraction was approximately 20% and the aortic and mitral valves were evaluated. It says, we consulted cardiology during this time to read echograms intraoperatively to assess the level of the mitral valve or mitral regurgitation, once the patient was weaned of the cardiopulmonary bypass, and there was some anotropic support. They noted the mitral valve regurg was more severe than the pre-op, so at that time they decided to replace that mitral valve. This time we realized that if the patient goes back on cardiopulmonary bypass to replace that valve, they're going to need some sort of support, which included an intraaortic balloon pump and or ECMO. Just note to yourself, just so you know, cardiopulmonary bypass, if you think about this, so they're stopping your heart, putting you on this machine and then restarting your heart. The more you're doing that, going back and forth, on and off bypass, the more stress that puts on the heart. So a lot of times you will see this scenario where they're going to give aid to that heart, especially a severely diseased one. All right, so they went on and based on the TEE, they reapplied and cinched down the SVC and IVC cannulas, so they put them back on bypass. The sonographic groove is then dissected and opened by visualization on the mitral valve and they noted that it was structurally intact with some elongated anterior leaflet cords. Then they placed those sutures along the annulus of the mitral valve and then followed by sizing of that valve to a 29 magna ease. They sutured the valve in place. Once the valve was tied down, the left atrium was closed and now we have code 33430. Dropping down, they also did a left femoral artery intra-aortic balloon pump was put in place percutaneously. So now we know we have 33967, which is our balloon pump percutaneous. Dropping down, the patient continues to need a significant amount of cardiopulmonary support, so then they decided to also do an ECMO with the balloon pump. So the femoral cannula was moved up to the SVC cannula. Keep in mind, when they put this patient on bypass on the previous slide, they went percutaneously. That's how I knew to pick the 33952. Femoral cannula was moved up to the SVC and it was clamped and then removed by a snaring of the cannulation stitch after brief positive support, the circuit was switched to the ECMO. Then they put in their chest tubes. Chest tubes are not separately billable. There is a little bit of exception to that rule. I know I'm coming up on time, but I'm going to go through this pretty fast. The exception to that is if the patient had a known pleural effusion and they put in that chest tube for that, then they can. But normally, chest tubes are included. All right, so these are our codes. We have replacement of mitral valve, aortic valve, redo of the cavage, the ECMO percutaneous, the percutaneous balloon pump. Note, I did not code the 33947 because there was no documentation of that ECMO initiation. So that would mean to go back to the provider. More than likely they did, but it's not there, so I can't assume. All right. So this patient, we had moderate to severe aortic insufficiency, multivessel CAD, atrial fib with rapid ventricular response and congestive heart failure. They dissected around the right side of pulmonary veins circumferentially, placed an RF plant and placed a total of six burns. Then they dissected around the left side pulmonary veins, took down the ligament of Marshall and did another six burns using the pulmonary isolation device. So remember, we're only around the pulmonary veins. We did not talk anything about that atrial ventricular annulus. Then they dissected the left atrial appendage and put in a clip. That clip's included in the maze. We're going to code the 33257. Next, this is also a cavage. So they did a right coronary artery opening. They created a distal anastomosis to the greater saphenous vein, that's one vein. Then they did their distal flow, vein was measured, and then oriented to the ascending. Next they looked at the single obtuse marginal, and it was dissected longitudinally. Then they sewed the second vein to that one, so we have two veins. And then moving on, I know I'm going through this quick, let's see. The seven proline suture was created, left internal mammary artery was also done. That's the 33533. So we have one artery, two veins. We have the 33518. There was no mention for the endoscopic vein harvest. They went on and evaluated the aortic valve, decided to replace it. It was sized. So then we coded the 33405. Again, these are our codes. I did not code endoscopic vein, nor TEE, because the endoscopic vein was not documented and the TEE didn't meet any requirements to code for the surgeon. I don't know who interpreted it. All right, our last case, this one's pretty quick. We have status post aortic valve replacement 10 days prior. They also have a status post maze. So what happened? Well, the patient developed a pericardial window and evacuation of the left pleural effusion was needed to be performed. So they reopened, they took the patient back to the OR. That's important. They took him back to the OR. So now we have a 78. Given the size of the effusion, they decided to place or to perform a window. So they did that sternotomy and they gained access to the pericardium. They did the remove 500 milliliters of Serenganga's pericardial effusion. We have 33025 with a 78. Talks about the TEE, but again, I don't know who actually performed it. Then they also did a 78. Then they also placed a pleural chest tube for that effusion. Once we went back to the OR, we're going to code this with the 32551 with a 78 modifier and a 59 because it does bundle with a pericardium. This is pleural space. This is pleural. This is pericardium. You can unbundle that with a 59. Here's our final answers, 33025, 32551. Both have the 78. Again, you have the 59. I answered questions as I went along. We will combine them and get them out to you. We are going to do a webcast hopefully this month. We're aiming for it on the final rule. It is out, but it's being dissected. And then keep these dates in mind for our December boot camp. I appreciate your time and patience. I appreciate the fact that you let me go over three minutes. Like I said, we will assemble those Q&As and get them on the Academy probably sometime next week. Thank you all. Have a wonderful day.

video

Michelle Platt

Jolene Bruder

heart procedures

coronary artery bypass grafts

aortic valve

mitral valve

anatomy

function

common issues

procedures

CPT codes

clear documentation