All right, well, hello and welcome to our webcast. My name is Jolene Bruder and I'm a Senior Coding Consultant with MedAxon. Today, we're going to review cardiac cath and PCI coding, and then we're basically gonna delve into specific cases. So most of the cath and the PCI information is gonna be more of a review, but, cause we really wanted to focus on case examples themselves. So as always, before we get started, to access the slides for today's presentation, you will need to click on the chat box to access the link here. Please do not use the chat box for anything else, especially questions. Questions, we will need you to submit them through the Q&A box. And we do ask that you keep your questions on topic. And we will also answer as many questions as we can during the webcast. I have my RCS team with me and anything that they can't answer, they will. As always, we have enough time. We will address the questions at the end. And then of course, as always, we will be compiling all of them and those will be found on the Academy website. And speaking of which, there was a lot of flurry of activity on the listserv today about CEUs. So if some of you are, if this is your first time actually joining one of our webcasts, now that we're in our new format, just to let you know, we are no longer emailing CEUs. Number one, it was very daunting and a very manual task. And it took us longer to get them out to you. But now how this happens is they are available for the AAPC. They're going to be available to view and download in the transcript section of your MedAxium Academy account. There's a couple of caveats to this. First off, you have to make sure that you are individually registered for this webcast. And you also need to launch the webcast in order to get credit for the CEU. AAPC does require that people listen live when we offer our webcasts on demand as far as listening, but not for CEU purposes. So again, if people can't make it today, they can always go back and listen, but they cannot get that CEU unless they actually launch the webcast live. Now, that also being said, you can still listen as a group, but just make sure again that you individually launch it. We are asking for one to two business days after the webcast to get these CEUs added to your Academy account. But we started this in July. So every CEU for every webcast that you've listened to from July on is now available in that transcript. So later on, if it's time to send your CEUs to the Academy and you're missing one, you can go back and look in your transcript and get it that way. Now, obviously the ones that were done previous to July, they're not going to be on your transcript. As far as our BMSC holders, those certificates are also available. And as always, you will directly email me to request that. All right. So this is our disclaimer. And as always, we just want you to know that this does not constitute legal reimbursement, coding, business, or other advice. You always need to check with your local Medicare carriers, and you also have to follow your commercial carriers guidelines. You can consult with your practice's legal counsel as well for any coding and reimbursement advice. And then this is our CPT disclaimer. All codes from this content are, basically they belong to the American Medical Association, and they were taken out of the CPT 2022 publication. So again, we're going to review some of the coronary angiography coding, review the intervention, including PTA, stent, atherectomy. I do have a couple slides on the lithotripsy, which we got a new category three code starting in July of this year. So we'll go into that a little bit. We don't know a lot about it, but you know what we do have, I'm certainly going to share with you. Then we're going to cover some just basic coronary angiography cases, and then we'll get into some interventions. And then of course we'll have our Q&A session. All right. So starting off, we have three types of heart counts. One is for the right chamber, one is for the left, and then one is a combination of both right and left. Caths are performed for either acquired disease or congenital. Keep in mind, congenital caths are not just for children. There are adults that still have issues. And today we are not covering any congenital cases. We do now and then provide webcasts that have where we cover the congenital cardiology. That will not be the case today, but I just want you to keep in mind that sometimes it's not just for acquired heart disease. All right. So these following items on this slide are included in cath procedures and they're not separately billable. So any introduction, positioning, repositioning of the catheters themselves, recording of any intracardiac and intravascular pressures are included, ultrasound guidance is included, any acquisition of blood samples, gases, other dilation, things like that. Venous infusions during coronary intervention are also included. The drug may be separately billable, but that depends on if you own your cath lab or not, or the facility more than likely will be coding that. If you own your own cath lab, then you may. Closure devices are also included. And of course, any post-angiography that is done to make sure that, you know, if they do the intervention and they do that follow-up angiography to check their work, that is not separately billable. And then these were a couple of things that, you know, if you want to share this slide with your physicians to make your life easier, I highly recommend it. Things that need to be in the report are obviously the access point. Did they come through the femoral artery? Did they come through the radial artery? You know, for right heart cath, they have to go in through the venous system and go up through the inferior vena cava into the superior vena cava. Any imaging that's interpreted that needs to be documented. Intention of the cath, was this actually diagnostic or was it roadmapping based on a prior study? So if, you know, let's say I had a heart cath a few weeks prior and they're bringing me back in today for intervention, well, unless something has changed, they cannot charge for that angiography again. Catheter movements should be documented. Cath placements at the time of the injection is, it's really nice to have that very clear picture of where that cath went. You know, basically I used to give a talk to physicians on the five W's and it was who, what, where, when and why. And basically it was, you know, who was the patient? Where'd you go? How did you get there? What did you do once you were there? And, you know, what was our medical necessity? What's our why for doing this? All right. So coronary angiography, you can see here, we have the 9, 3, 4, 5, 4, which that cath will come up through the aorta and then they'll individually go into those coronary vessels. So we have the circumflex, actually we hit the left main first and then that splits off into the left circumflex and the left anterior descending. And then back over here is the right coronary artery. Keep in mind that circumflex actually runs behind the heart, but you can't, you know, for purposes of this picture, we don't have the 3D version. So that's why it's more over here. And then 9, 3, 4, 5, 5 is again, we have cath placements, but then they can also be placed in these graphs. So we have like, this one's the left internal thoracic artery, which is better known as the lima. Normally the lima when used is sewn to the left anterior descending. And then over here, we have a, this says grafted femoral artery, but it could be a vein. You can use arteries or veins, just depends. And that's a whole different section or session to discuss the CABG. All right. So for left heart cath and coronary imaging, the catheter actually needs to cross the aortic valve in order to be a left heart cath. Otherwise it's not, it's just your coronary imaging, which I just covered on that previous slide. For the 9, 3, 4, 5, 9, not only was the valve crossed, but then you have the images of bypass grafts. So again, if they don't cross that valve, then you resort to the 9, 3, 4, 5, 5. You do not use the 9, 3, 4, 5, 9. Now this question we get a lot, and basically it comes up. So what if the physician's actually looking at the left internal mammary or the right internal mammary, better known as lima rima, how do we code for that? Well, because years ago, and I'm dating myself here, there used to be a code, but that's been, wow, probably over 12 years ago, I'm thinking. Anyway, basically what we have to do now is it needs to be very well-documented that the patient does need a coronary artery bypass, and, or known, better known as a CABG, and that the physician is actually looking at the lima and rima as potential bypass graft. In some cases, if that's well-documented, some carriers will allow the 9, 3, 4, 5, 9. This is something, though, you need to check with your carrier and find out if they will. So, again, what flies in Palmetto may not fly with WPS, and NGS might, it's just, again, it depends on what section of the country you are and what your individual MAC will or will not allow. So just to kind of give you the better diagram, so normally they'll come up through the leg, they can come through the arm, but they'll thread that catheter up through the aorta, and then it comes out here, and at the bottom of the aorta is where your aortic valve is, and they have to come through there and into the left ventricle. Now, sometimes they'll do a left ventricular gram. It is not necessary to do that imaging, though, in order to bill a left heart cath. They do have to cross that aortic valve, though. So we'll kind of talk about that. So how do you know? Well, ideally, they should document that they crossed the aortic valve, but I also know that sometimes that's challenging. So there's things you can look for. Again, you can look for that LV gram, but keep in mind, they don't have to do the LV gram. So if they don't actually do the LV gram, then what do you look for? Well, you're gonna look for ejection fraction, if that's documented, or you can also look for LV pressures, and those might be noted as LVEDP or EDP, and the EDP basically stands for end-diastolic pressure. So if you see that wording, then you have a left heart cath. But again, like I said, ideally, it'd be nice if they would say they crossed the aortic valve, but we live in the real world, and we know that they don't always tell us all that. All right, so now looking at the right heart cath, so now we're concerned about this side of the heart. And to get to this side of the heart, the physicians have to go through the vena cava. So they'll come up through here. The cath can come from the leg, it can come from an arm, it can come through the neck or the chest, but basically they have to come into the vena cava, and then they enter the right atrium. Sometimes they'll go out here into the pulmonary arteries, and they can go down into the right ventricle as well. But for the right side, we're looking at the right side of the heart, not the left, when it's just a right heart cath. So these are some add-on codes that are done with right heart cath. So the 93451 is actually the primary code. Then you have add-on codes of selective right ventricular or right atrial angiography. If that's done, then you code this add-on code. And notice on the slide here, I've listed the codes that it is allowed with. And this is not with your typical left heart cath. Now, if they're doing a right and a left heart cath, then this code will add on to that. Same with the pulmonary angiography. They have to be on the right side of the heart for this to happen. 93463 is that pharmacological agent that sometime is used that has to be before and during. And then the physiological study is also sometimes done, and that is usually the patient's on a bicycle or treadmill. They're not done a whole lot, but I've listed the codes that they add on to. Now, these two, the 93463 and the 93464, will also add on to your left heart cath codes. So for our combination, when they do right and left heart cath, we have four codes. For 93460, we have the right heart cath and the left heart cath, as well as coronaries imaged. Now, this also means that the aortic valve was crossed. Again, you don't have to have that LV gram, but if it does, you know for sure they crossed the aortic valve. In 93461, that includes everything that's in 60, but now you also have those bypass graphs to visualize. If they don't cross the aortic valve, but they're still doing a right and left imaging, well, then you have 93456 for the right side of the heart, and then also the coronary arteries that are imaged on the left side. 93457 is the same as 56, but again, now we have those graphs. So if they don't cross the valve, you're either coding 93456 or 93457 for that combined right and left heart, or if they do cross the valve, you either have the 93460 or the 61. So here's some other things that are done. We have the fractional flow wires, or better known as FFR. We also have IFR. Well, IFR, there's been some controversy coming up on this as well. I believe the AHA came out and said we should use unlisted code, but we haven't seen anything from anyone else, from CPT, AMA, anybody else coming out saying that we can't reduce it, the regular code. And the reason why we have to reduce this is in this, in the IFR, they do not use a vasodilator, so it's not fully meeting the 93561, or I'm sorry, 93571. And so that's why we reduce it. Again, do whatever your carriers tell you. If you're, you know, if you're not getting denials on this, I wouldn't worry about it at this point, but if you start getting denials, then obviously you're going to want to get ahold of your carrier and see maybe if they do want you to report an unlisted code instead. Now, keep in mind, because this comes up a lot too. So what happens when, let's say Dr. Seuss, Dr. Seuss does a heart cath, and then Dr. Welby, again, I'm dating myself, Dr. Marcus Welby comes in and just does the FFR or the IFR. Now what do you do? Because you have two separate sessions. These are add-on codes. In that case, you do have to code an unlisted code if nothing else is done, because you can't charge for the angiography, again, unless you've met the requirements of the patient's condition change, or, you know, all those rules. And I cover that in a later slide in case you're new to this. But when this is the only service that's done, then you're going to have to use an unlisted code. But normally if it's, you know, if they've done the heart cath or they've done an intervention and they've used the flow wire, then you code the 93571. If they perform the IFR, which is instant radio wave, if they, or you might even see DFR, D as in dog, if you see those, then you're going to have to reduce them. We also have intravascular ultrasound. This kind of shows you what the transducer looks like. We have the primary code and then the add-on code. Again, we have medically unlikely edits of two. Two vessels can be reported. You'll have to check. I can't remember if clinical, if it allows three. If it does for that clinical portion, then you can code more than two. You can possibly code up to three. You'd have to check it for sure. So don't quote me on that. But again, if you have to do that, then you're going to have to appeal because it will deny normally and you'll have to send in the IPR3. Also notice that the IVUS is also used for that optical coherence tomography, better known as OCT. That's included in that IVUS code now. But again, they don't have to do OCT to code the IVUS. We also have add-on code 93462, which is for the left heart cath by transseptal puncture through an intact septum or by a transapical puncture. These are often reported with EP ablations. They do bundle, I know, with the AFib ablation. Sometimes you'll see them with a left heart cath. But again, it's not done often. And then again, and I already covered these, we have the pharmacological agent and the physiological exercise studies. And again, these can be done with left or right heart cath or the combination cath. We also have an add-on code for aortography. Now, there's always confusion with those two. The aortography means you're actually looking at the root. Oh, sorry, I clicked. At the root of the aorta. We don't care what's going on up here. Up here does not constitute this code. They have to actually be looking at the root. If they don't, then there's other 7,000 thoracic codes that you can code for that. But for 93657, they are specifically looking at the root. All right, so now we're going to jump into our percutaneous intervention. Now, keep in mind, so the diagnostic cath, when can you bill it with an intervention? Well, first off, there can't be a prior base coronary angiography study available. If it is available and a full study was done, decision to intervene is based on that diagnostic angiography. This will be the same day. This slide's kind of confusing. I don't like this slide. So let me put it in my own words here. So basically, with coronary angiography, if I'm coming through the ER with chest pain and they're like, we're going to do a coronary cath, figure out what's going on, and they decide when they're doing that cath that I need intervention, that's billable. Now, different scenario. I had a cath two weeks ago. I'm coming in to do an intervention, and everybody already knew it. Nothing's changed. They're able to read the images. Nothing changes while I'm having the intervention. Then that diagnostic cath is no longer diagnostic. It basically becomes a road mapping. So keep that in mind. So it's very important that your physicians document in their indications whether or not this is truly a diagnostic cath, or is this based on a cath that happened prior. Now, Medicare does not define what they consider recent. So they don't put that in black and white. So some practices consider the previous six months. Some go with three months. That's kind of a policy your practice has to decide and live by. And that does not mean that Medicare is going to honor it. Also keep in mind, this applies to CT angiography and MRI angiography. So if that's done and there's no change, you don't have the change in the condition, and you don't have the individual or inadequate visualization documented. So let's say I had that cath two weeks ago, and they're like, we really couldn't read the imaging real well. We need to look again. As long as that's well-documented, then you can bill for that diagnostic cath. All right, so these are some of the ways we treat stenosis in the arteries. We have a stent. We have angioplasty, which is with a balloon. And then we also have atherectomy. Now, atherectomy can be directional. It can be rotational. I like to think of atherectomy as if you think of plumbing in your house, or even what's going out to your sewer outside. And sometimes tree limbs get in there and clog all that up. I don't know if everybody has one, but we call them roto-rooter. And roto-rooter comes out and runs a snake through. And it's basically a directional machine that cleans out all the tree roots. Well, this is basically the same thing, only now we're talking about the vessels of your heart. And that'll get rid of some of that very stubborn plaque. The stent is normally launched with a balloon. And then when they remove that balloon, the stent here is left in place. Or they can just choose to do balloon. Stents, there's also drug eluting. And there's bare metal. Now, for physician purposes, when they're doing this billing, it doesn't matter if it's a stent as a stent, whether it's bare metal or drug eluting. That does become, you need to know, you've seen things about C codes that happens with facility coding. Your physicians themselves are not going to use those codes. All right, so here's our primary codes for percutaneous coronary intervention. We have the stent and atherectomy. We have atherectomy only. We have a stent only. We have balloon. Then you also notice we have the stent and atherectomy additional branches, atherectomy only additional branch, same with stent and same with balloon. We'll get into the branches here in a minute. But this is just basically your set of codes. Now, for this group, stent and atherectomy is king. It's the highest out of this group. But it's not the highest that can be done. That brings us to this slide. So now we have the acute MI, and that's what AMI stands for. We have CTO, which is chronic total occlusion. These two are actually weighted the same. But you're not normally going to treat an acute MI and a CTO on the same day. CTOs are normally planned because this is something that has built up for at least 30 months. Bypass graft is another. Any method code, and then we have additional CTO, and we have additional branch for the bypass graft. We dealt with the acute MI. And the reason why is you normally only have one culprit lesion. There's one lesion that caused that myocardial infarction. The doctors need to be very clear in their documentation on this as well as to what lesion that is. Because sometimes maybe the acute MI happened in the right coronary artery, but while they're there, after they fix the right coronary and they decide, oh, there's one over here in the LAD that we also want to put a stent in, well, you need to know which one was which. Which one was the acute MI, and which one was just a lesion that they decided to stent or balloon or whatever they end up doing. Keep in mind, if you have a chronic total occlusion and a bypass graft, you're going to code the chronic total occlusion. And I actually have an example of that in my case studies. So our coding concepts for percutaneous coronary interventions. There's actually five major coronary arteries that are recognized. They have modifiers, which I'll show you in the next slide. There's three coronary arteries that have recognized branches for billing purposes. So those five coronary arteries are the left anterior descending, the left circumflex, the right coronary. Again, this is on the next slide too. So don't feel I'm going too fast and you've got to write all this down because it's on the next slide. Left main and ramus intermediate. The ramus and the left main do not have recognized branches for coding and billing purposes. They have them, but they're not recognized for our purposes. So it's a clinic. So if they treat a branch off of the left main or the ramus and they also treat the left main or the ramus, you only code one. You don't get an additional for that. Again, our ending method codes are the chronic total occlusion, the acute myocardial infarction, and then interventions either in or through a bypass graft. So keep that in mind too. So maybe the lesion isn't actually in the bypass graph, but they have to go through the bypass graph to get to it. Now you're going to code that nine to nine through seven. And what they mean by any method, it doesn't matter if they use a balloon. It doesn't matter if they use a step. It doesn't matter if they use an atherectomy or a combination of them. That any method code means any method. I know when they first came out, people were kind of confused and thought you had to have all three and you don't. Again, diagnosis specificity is critical for you to build the correct code, because these are weighted a lot higher than your normal lesions. So it's important, again, that your physicians are actually documenting very clearly what is going on with the patient. And if if you're not sure, and it almost looks like maybe it's an acute in my or maybe it isn't, you know, maybe they're calling it a total occlusion, but they didn't call it a chronic total occlusion. These are things you need to go back and discuss with your providers. Never assume anything and try to help them out to give you better documentation. All right, so again, these are the five major coronary arteries. These are the modifiers, the HICPIC modifiers that go with them. Now, keep in mind, not all carriers want those modifiers reported. A lot of them do, but there are some that don't. Some of your commercial carriers don't want you to report these modifiers. So when in Rome, you've got to do what what's going on with the Romans. So, again, for our branches, so we have two branches that are recognized for the LAD, which is I mean, there's more branches. If they treat three branches, you really only bill for two, because that's what we have. We can build these up to two. Again, that's possibly something you can appeal if the documentation is really good. But for the LAD, we're looking at diagonals for the left circumflex. You'll see marginals on or there'll be I cannot think of the word. It starts with an O, OM, the OM1, OM2. Those are the marginals. Then with the right coronary, you have the PDA, posterior laterals. You can actually Google pictures and it'll it'll tell you really well. It'll mark these out. All PCI performed in any segment of a vessel, whether it be the proximal, the mid or the distal of that main coronary artery, is still only coded with one coat, it's still only reported with one coat. If they happen to let's say they treat a lesion in the LAD and then they also treat a lesion in the first diagonal and a lesion in the second diagonal, you can build the primary code for the LAD and then you would also build an add on codes for the additional branches if they treat. Now, this gets confusing, too. And I see this more on doctors than coders. Sometimes doctors will they'll treat not only the LAD, they might treat the circumflex, the right coronary, and they might put a stent in all three of those. But sometimes instead of using three primary codes, if they're doing their own coding, because some of them do, they might use the nine to nine to eight, for instance, for one of them, and then use nine to nine to nine for the other two major coronary arteries. You don't ever want to build that because each one of those are separate vessels and there are separate families. So think of the LAD as one family and the diagonals belong to that family. That's their kids. The right coronary, you have, again, the PDA and the posterolateral. Those are their kids. So if you're you know, the LAD is neighbors to the Ramos and not everybody has a Ramos, but the LAD is neighbors to the Ramos, the left main, the left circumflex, and of course, the right coronary is kind of down the block farther. But keep in mind that that we're talking about what's going on in that one vessel when we're talking about the main, the parent and then the children are the you know, the parent artery and then the children on the branches. So. Right, so what's not separately billable? Well, again, accessing, selecting those vessels. Any imaging that is directly related to the intervention. So, again, if they did that diagnostic study first, you know, again, the patient comes through with the chest pain. They do that diagnostic cath and they decide to intervene. That's billable. All right. Well, if they image again while they're intervening, while they're placing those stents or after that intervention, that's not separately billable. You can't code for that again. Traversing the lesion is included. Closure of that arteriotomy. That's also included. I get this a lot. So what if they're pacemaker dependent? Doesn't matter. Temporary pacemakers are never billable. That's an NCCI edit and it is not allowed. So and, you know, I know physicians can harp on you till the cows come home, but there are certain things that you just you're not allowed to bill for. All right. So let's talk a little more in depth on this chronic total occlusion. So, again, there's no antigrade flow through the true lumen. Normally, there are going to be clinic. The. Clinic criteria is there's going to be bridging collateral, you might see that documented that there and what that means is the body does try to repair itself, so it's got this big lesion hanging out there that's been there for a while, it'll try to start feeding. It'll branch off and make its own little branches to try to keep getting blood flow to the heart. So or to whatever suction that this is blocked off of. So you'll see things like bridging collaterals. There'll be calcification at the occlusion site. No presentation with ST elevation. So keep in mind that chronic total occlusion is not an ST elevation. So it's not a QMI or an acute MI. There's no Q wave issues, anything like that, because they're two separate things. Chronic total occlusion is something that's been there, but it hasn't caused an acute MI, but it's obviously blocking flow to the heart. So it's normally a problem. I mean, they're not going to just let it go. But, you know, that that presentation is different of a chronic total occlusion versus an acute MI. So, again, our acute MI that is percutaneous transluminal revascularization, acute total or subtotal occlusion, and this is during a mild cardial infarction. It can happen and it can be in the coronary artery or the coronary artery bypass graft, it doesn't matter what combination you use. This does include aspiration thrombectomy, which we'll talk about in a couple more slides. So we get this a lot, too. So the acute MI. So let's say I came through the ER, they couldn't get me into the cath lab right away for whatever reason. Maybe I wasn't stable enough. And then by the time they get me to the cath lab, maybe it's two, three hours later and I'm no longer having symptoms. I'm no longer in acute MI. I'm. Not saying that it's not serious, not saying that the diagnosis is an acute MI, but I no longer qualify for this nine to nine, four, one. Most of the time in STEMI's are not considered acute MI's, but they can be on. You know, there's an old rule, never say never. So I we don't ever want to say never can an STEMI be an acute MI because it can be. But they have to be symptomatic. It has to be documented. They have to. Actually activate the cath lab in an emergent situation. Again, I have a case study that will go through here and we'll talk about that. There's also there's a lot of information. The CPT assist, AMA. There's all kinds of situations out there that that fully describe that. I did not include all of this in the slides because, again, I want to focus more on the case studies versus. You know, the general information on this, this is a review. OK, so again, we have the bypass graph code and again, either that you either have to go through the graph to get to the lesion or the lesion is in a graph if it involves a branching or Y graph. If both sections are treated, then both are coded. So sometimes picture, but sometimes they'll do when they do a bypass, they'll take that vein and they'll split it. So they might sew it to the the left circumflex and then again to one of the marginals and they'll split that off. So it becomes a Y graph. You might see some sequential graph. If each part of that Y graph has to be treated, that's two separate lesions. They think of it kind of as a bifurcated lesion. I'm sorry, not sequentially is the wrong word, sequential graph is one graph and that's basically it's just a graph that they had to keep sewing on to. But an actual Y graph, you have those, you know, you have that bifurcation. So think of it that way. You can use two base codes, one bypass and one primary if lesions are both in the native and in or through. So if you treat, let's say we treat the proximal LAD and then they have to go through a bypass graft to get to a distal, then you can build both. That doesn't happen that often. Again, this is any method. It doesn't matter if it's stent aperectomy or balloon. All right, so let's get to this lithotripsy. So the shockwave lithotripsy became a category three code starting July 1st. As we know, category three codes are carrier priced. There's no RVU assigned. This code is an add on code. Um, and it adds on to all the intervention code. You have to discuss with your provider what code this should crosswalk to. I can't tell you. I don't know. And even if I did know, I'm not allowed to because this is up to the provider. It is, you know, it's based on the crosswalk code should be a similar type of work, the amount of intensity, the amount of time, the complexity. That's why you have to discuss this with your provider. Comparable code should also be an add on code, not a primary code. So keep that in mind. Modifier 80 is allowed with documentation. Now, that doesn't mean that that documentation is, you know, again, Dr. Seuss performed the stent and Dr. Welby performed the lithotripsy or assisted with that. And now he automatically gets an 80. Keep in mind with your 80 modifiers, there are certain codes that the 80 modifier is allowed with just that description I gave. There's other codes that they allow the modifier 80, but there has to be documentation as to why it was medically necessary to have that assistant. So that's that's what you're looking for. It's not just to it's not just to document that an assistant was there or participated. You have to give the medical necessity as to why you needed an assistant. X modifiers, 59 modifiers are allowed. Interestingly enough, when I look at the vessel modifiers, the LD, the LC, they're not listed on the with the AMA CPT code. You know, we we actually met actually uses Encoder Pro to check things and they're not listed on there. I'm not saying that you can't use them. I don't know. You know, I'm I know as much as you do. And I don't have a crystal ball, as Nicole likes to say. So, again, this is something you're going to want to check with your carriers. All right. So talking about those major coronary arteries again, this is some our guidelines. You want to build the highest primary code per major coronary artery. So if we stand in the LC, you're going to build that as a step. If we do a balloon and the RC and that's all they did, then that is going to be your highest code there. If they do an AMI in the LD and then a stent in the LC, you're going to code that AMI for the LD and then you will code the stent for the LC. So keep that in mind that, you know, these three here are they're actually. The major king here, but you always want to keep in mind that you want to code whatever is the highest. And per vessel, that's done, you can build up to two branches for the LAD, the circumflex and the right coronary, but not the ramus and not the left main. And again, this kind of beating the dead horse, use one primary code for each coronary artery. Additional procedure codes are limited to the artery where a primary code has already been used. Again, you'll build now, let's say because we get this a lot to then this is mainly with narrow coders, but you want to build for. If they treat the branch and not the parent, so they're treating the child, but not the parent. It's OK to still build that primary code, you can't you're not going to build additional branch because you never treated the parent to begin with. So in that scenario, that branch actually becomes the primary situation. So let's say they they treat the first diagonal and they treat the second diagonal. One of them is primary. The other one is going to be additional. But always keep that in mind, if they only treat in a branch, you still have to build a primary code. All right. So, again, let's talk about these lesions and two vessels. So the the example here is I have one lesion that stretches from the left main into, let's say, the left circumflex. If that one lesion can be treated with one step, so they put it, you know, they're crossing over into their territories because it's not like the lesions are forming and then go, oh, we're going to hit the circumflex, we got to stop now, they'll go all over. But if one step can actually treat that and open up both of those vessels with that one step, then you bill it as one. Same scenario, but now we need a separate step in the left main and we need a separate step in the circumflex because maybe it's really long and that one step is not going to cover both. So if you have two separate actual interventions in each main artery or wherever your bifurcation is, then you can code for two interventions. But if it's one stent that's covering both, you will encode it once. And this. Yeah, bifurcating lesions, those are actually this was I confuse myself, this is the same lesion that goes over to so like here it would start here and then come in here to the LAD, let's say, and you treat that with one step. Now, true bifurcating lesion. So you have a lesion here and then it bifurcates into the branch. Well, you stents don't go around corners, so you're going to have to treat both of those. That's not just one stent isn't going to cut it. You're going to have to treat each vessel. So therefore, again, you would build a primary here and then a branch. If you're up here at the left main and as it bifurcates into the circumflex and the LAD, then you're going to put a stent in the circumflex and they put a stent in the LAD, you code both. All right, here's our other controversial mechanical thrombectomy. I sure wish they would. Update the guidelines on these, but they haven't as of now, as of the as of today, the of this broadcast, Angiojet is still only the approved mechanical thrombectomy. I know the venumera catheter has come out and calls itself a mechanical aspiration thrombectomy. If it has the word aspiration, it's not mechanical. It's a suction. Mechanical is a whole different. Angiojet is a whole different machine that's being used. And if you actually go on Angiojet website and of course, it's it's patented. Boston Scientific, the very first slide, if you go into Boston Scientific and you Google or go on their search engine and click or type in Angiojet, it comes up. This is the only FDA approved method for mechanical thrombectomy. So until that actually changes, all this stuff is nice, but it's already included with your acute MI. Now, if they do and if that's all they do. That's nice, but it's included. Nine to nine, seven, three. Is an add on code, so you have to have a primary first. And again, Angiojet aspiration does not count. All right, let's get into our cases. So for our first case now, we have asked people have asked on the last few of our webcast that we cover ICD 10. Now, I'm going to tell you flat out, all I have here are reports. I don't have the chart. These are cases that we've that members have sent in at different times and have asked us for help with. I don't have this patient's chart, so there's going to be some unlisted or not unlisted. There's going to be some unspecified codes used in these, and that's because I can only code what's here. So and we're not focusing on ICD 10. I'm just adding this. We're focusing on the on the actual case studies themselves and what's going on with the procedure. So we have a presentation is and it's not specified. Patient also has an abnormal stress test. So that's why I have our nine four three nine point three nine and I twenty point nine. So this is all the consent and everything that they talked about. I'm going to read the blue words. So they start off from the right femoral artery using a Solinger technique and L four coronary catheter was brought up into the ascending aorta. So keep in mind they're down here in the legs when they come up through the aorta. And now they're here and he goes over or she goes over into this right coronary artery and does an injection and then they did multiple views. Then they did a left ventricular agraphy. Well, what does that mean? That means they cross that aortic valve and they're over here on the left hand side of the heart and they did that LV gram. So now we know we have nine three four five eight. They also did. Oh, I'm sorry. When he first came up through the ascending, he did the left side, too. They also did this right common femoral, superficial femoral, profunda femoral. That's nice. But this was done for closure. We don't code for that. There has to be medical necessity in order to code for an extremity. Angiography. Angioseal does not cover that. So then the patient was brought back to the cath lab and was stable. And then we have our moderate sedation blurb here. And he basically states what the drugs were and that they supervise an independent trained observer who pushed the medications, monitored the patient's level of consciousness, physiological status throughout the procedure. Gives me the time. So let's talk about that. So ideally, it'd be nice if they would actually list who that independent trained observer is. But that's. They don't always do that. Pick your battles. You know, you can mention it, but I wouldn't I wouldn't not code this just because it didn't list who the independent trained observer was. Enter service time. They did give a total time of 30 minutes. As far as I know, total time is fine. Some carriers might be picky and want to start and stop. So, again, that's up to your carrier. But for generic purposes, we're going to say that's good enough to code that 99152. Now, over here, this gives me all the hemodynamics. This is that left ventricular gram. I also have the 128 over seven. I have LV pressures. Aortic pressure is not good enough. You've got to have at least LV pressure. So had he not said he did the LV gram, I wouldn't have known for sure other than the fact I have those LV pressures. Then, of course, we have all of our findings. Of the vessels themselves. A state's mild, nonobstructive coronary disease, if I had actual percentages, I would probably code that as CID, but I don't I don't have a chart. So please don't hang me when I give you the answer of I'm going to stick with the diagnosis of I twenty point nine are ninety four point three nine. We have the nine, three, four, five, eight, twenty six modifier, if you don't own the facility and then 99152. Case number two, this patient presents with pulmonary hypertension. And also dyspnea, well, in this case, I'm coding the pulmonary hypertension again, I don't have any other specifics other than that, I will not code the dyspnea because that's a symptom of the pulmonary hypertension. So I'm not going to code that. Procedure that was performed was a right heart cath. Again, I'm going to drop down here. This is all important information, but I'm not going through all of that. So it comes from the right femoral artery using a Selinger technique. And the sheath was flushed, then they placed a right or a swans gang calf. Which. It's kind of strange. Because I didn't document the vein that they went through, but again, these are real world, this was something I would have taken back to the doctor and say, can you please do you mean vein? But anyway, so that's why the catheter was used for right heart cath. Let's talk about that swans catheter. If they only place a swans catheter for monitoring purposes. Hang on, I just a question just popped up, where can I get access to that chart for the percentages of the CAD? These are not. I don't have access to the chart. These are cases that were sent in. So what I'm saying is when you're looking in your at your specific case studies, these are things you take back to your doctor and say, can you give me actual do you feel this is truly coronary artery disease? If so, then you need to either give me an addendum and tell me what the percentages were or we're just going to leave it as unspecified Angina. My point is, I don't have access to the chart, so I'm not. Um, because somebody just sent me the case, so I'm not in their office. I don't have their chart. All right, so back to this one and the swans. So the swans catheter, if they use it as monitoring purposes only, they come in and they place that swans catheter and the patient goes back to their ICU or wherever they're going, because somebody wants all these pressures monitored, that's when you code the swans cath. When they actually perform a right heart cath, you do not code for the swans, even if they leave with the swans in there. You're still going to code the right heart cath if a full right heart cath was performed. If you're not sure, again, that's something you need to discuss with your physician. All right, so he discussed this with Dr. Seuss, no challenge was recommend no challenge was not recommended. Makes makes as a closure device was applied. Patient was transported back with stable vitals. I have the nine, three, four, five, one. This slide shows also that we have moderate sedation. And then this gives me all those hemo dynamics of the right heart cap. So I know that they did it. He did have mild elevated heart pressures, that mean pulmonary artery was thirty two millimeter hurts. And then RBSP was fifty four. And this gives you all what happened during that right heart care. OK, so we have the nine, three, four, five, one with the twenty six, I have the moderate sedation and again, my diagnosis is the I twenty seven point. Case three. So for right now, we have exertional dyspnea and normal perfusion imaging studies, so I have the R zero six point zero nine and then the R nine four point three nine. So this one we're doing a left heart cath. He's also doing coronary angiographies. Again, this is the wish list. Don't code from this. This all has to be verified in the report itself. Then we have an IFR, the right coronary, one of the left circumflex and one of the LAD. And then he does state that my moderate conscious sedation is 15 minutes. So this one, they went through the right wrist, so they're coming through the arm, the right radio. Well, that's right. Is this the patient's right? Not ours. Anyway, so he comes up through here again, we're in the aorta because he came from the arm and he's up here in the aorta, goes into the left ventricle. So we know he crossed the aortic valve because he's in the left ventricle and that pressure was assessed and then the catheter was pulled back across the aortic valve. This is a doctor who's listened to their coding staff and they're being very clear. Talks about that continuous hemodynamic monitoring, then did selective digital angiography of the left and right coronary systems. So, again, looked at the left side and then went over here and looked at the right coronary artery, don't get right coronary artery confused with right heart. And I and again that's mainly for my newer people. I'm not trying to insult anybody's intelligence here I'm just. These are questions that come up. All right, so then it goes on to say that he did select it or we already talked about that. He did coronary IFR was then performed and there's a section below that's on the next page. I'm going to go ahead and give the 93458, because I have a full left heart cap. And I'm also giving the 99152 because I have my time. Keep in mind with moderate sedation as well. As long as there's at least 10 minutes documented you can code the 99152. Now I didn't get into a ton of those similar slides. 99153 is if you own your cath lab. That is not coded by the physician that is coded by the facility. Or, like I said, if you own your cath lab. So don't don't code for those. All right, so the volcano IFR wire was advanced to the right coronary artery. And then, so again because it's IFR, I know they did not use any vasodilator so I have to reduce this code. I did add the vessel modifier, but that's up to how you report how your carrier wants you to report. Please, if you don't normally report the vessel modifiers, don't start reporting them because you listen to this webcast. Follow what your carrier's guidelines are. Then they turn. Let's see that was an RC then they turn to the left coronary system. That volcano wire was advanced to the LM. And then it was advanced across the intermediate left circumflex slash OM3, which is the obtuse marginal, that's the word I couldn't think of, obtuse. Keep in mind, the branches here don't count as extra vessels for our IVAS and our FFRs. You're just going to treat this, it's the LC. I'm going to add another code for a branch. Then we also have the IFR and LD. Note, I put a 59, you may need an X modifier here because, you know, we have two. This indicates that these were two separate vessels. If it's Medicare, instead of the 59, I would use the XS. If your Medicare carrier is accepting X modifier. Again, I have my full hemodynamics, I have that left ventricle, the LVEDP reading so again I know they crossed the aortic valve. You can't get to the left ventricle without doing that. And then again I have all of my main coronary artery, he does talk about 10% placking. Just kind of reading through some of those. Let's see. And then this is giving again the specifics of these IFRs, the specific findings. It's almost like that slide repeated. It is, I apologize. This was the same slide as the other I think what I did is I added the picture and forgot to delete the other one but this is just a show where they came in to the right coronary with the IFR then they did a left circumflex and the LAD. This is our findings. Again he states non obstructive coronary atherosclerosis normal left filling pressure no aortic stenosis does give that 10% plaque. But again, is that truly full CAD, I wouldn't code it based on 10% stenosis, but that is something I would discuss with my physician first. So always keep that in mind. So I have the left heart count. And then I have my three IFRs, and the RC the LC and LD, and I have my moderate sedation. Again, I cannot bill without reducing this because basal dilators were not used, that's the difference between the IFR and the FFR. IFR actually stands for instant wave free ratio. All right, so now we're actually going to get into some percutaneous interventions here. So for this patient we have unstable angina coronary artery disease status post catch. Please do not I still see this and I know Jamie does and my team see this please do not code these individually. There is a combo code. It's the I 25.110 for unstable angina and coronary artery disease. If it's unspecified and that is I 25.119. Please do not code just the angina or, and then also coronary artery disease. If they only have the angina like I think my first case was, that's fine. Or if they only have coronary artery disease then by all means use the I 25.10. But if they have that you need the combo code. The Z 95.1 because this patient has status post catch, which is the coronary artery bypass. This picture here shows again these bypass graphs so they're also going to be looking at not only they're looking at the native vessels, they're going to be looking at these graphs. So again, I have this one they came through the right groin of the femoral artery, and they advanced to the left coronary osteum and left coronary angiography was obtained so they'll appear at the left coronary. Then the catheter was engaged in the saphenous vein graphs and also the IMA to the LAD which would be this one here. This obviously isn't this patient's picture. This is just a generic picture. And then again they looked at the saphenous vein graphs. So I have, and they also obtain the left ventricular gram so I know I have the 93459, because I have the full left heart count, because they cross the aortic valve. I have the coronaries, and I also have graphs. The catheter was exchanged a whisper wire was passed to the distal portion of the large diagonal. A 2.0 sprinter was introduced and dilations were made to the nominal atmosphere. This balloon was withdrawn. We then deployed a 2.25 by 18 resolute drug eluting stent and deployed this at 2.3 to 2.4 millimeter in size. And an excellent step up proximally and distally. So no further dilations were performed. So, you're probably like, well, that's nice drawing but how do you know he's on the graph. It's on the next page. So, but I'll show you here, but that's why I coded 92937 with the LD, they remove the balloon and guide wire. And then they're talking about the heparin the patient received. No right heart pressures were done, LV and diastolic pressure is given gives me the ejection fraction. And then here I have my angiography findings of my coronaries. I have that there's a widely patent but no disease and I am a. We're talking about the left ventricular gram, and the intervention placement of a stent was seen. So here are my findings, which I probably would have gone back and told him you know this would have a nice couple paragraphs ago, or her. But within this we have the findings we have a total occluded led a patent Lima to the led large led diagonal vein graft is totally occluded. There is 95% obstruction in the mid portion of this. So therefore it was stunted so we stunted in the vein graph, that's how I knew to pick that code 92937. If I had not said anything about the, the vein graph, then I would have picked a 92928. They also noted there was a total occluded circumflex and total occluded right coronary with a vein graph that's also occluded. There's extensive collaterals from the left system to the right system, and the patient also has severe LV dysfunction. So, 92937 which is my any method in that bypass graph and or through 93459 because this was diagnostic. My diagnosis changed from just unstable Angela of CAD because I also have that bypass correct. Now if all the bypass graphs were patent that I would, I wouldn't have coded them with CAD and Angela. I would have just coded the Z 95.1 and I 25.110 but we know for a fact that there was occlusion in the graph. All right, case five. And then we have crescendo persistent Angela known CTO. Last cath was one month ago, so I better be have documentation in here saying that something's different in order to code another path, because he listed. He lists the left heart cath and the coronary angiography this provider did. But I'll just give you a hint. There's nothing documented that anything was wrong with that cat. So here I have I 25.718 for my Angela and the graphs, and then I have the I 2582 which is that chronic total occlusion. And again I have the Z 95.1. It's all documented. So this one the vein graph to the right was engaged with multipurpose and native RCA was engaged. We did coronary angiography resulted revealed total occlusion with no integrated flow and RCA RCA graph was still open and feeding that graph down to the native vessel filling retrograde. We then proceeded with intervention. So really, it's telling you right here. Basically, they did this imaging to kind of plot out what they were going to do. This is roadmap, this was not diagnostic. Um, let's see we proceeded with the intervention they use a pro water flex glide guide wire and heparin boluses were administered. The wire was actually able to cross the first lesion, the fine cross was then moved to a more distal location where another total occlusion was clearly present. And then we use the fielder XT to cross with moderate amount of difficulty. Then the fine cross was placed in the distal right and change out. So again, they're in that right graph. The area and the native right throughout the proximal mid and distal was pre dilated with a balloon. Then 2.25 stunts were placed the distal 2.25 by 38 millimeter. That's the 2.25 by 34 and then 2.25 by 30, the entire area was post dilated with a 2.5 and see to high pressure. I'm coding the 92943. Because if you remember, and our code description that includes bypass graphs, so I'm not coding the 9937. This is higher in the hierarchy than the bypass graph code. And again, he has totally included RCA successful opening of that chronic total occlusion, and they use three steps. So our answer here is the 92943. For that chronic total occlusion of the right coronary. Again, I have the I 25.718, I 25.82. This one, if you look at your ICD 10 guidelines, you're supposed to code this first, you code the I 25, whatever first before the 82. And then I have the Z 95.1 because the patient does have growth. Right. Case number six. This one we have a lithotripsy, drug eluting stent of the osteo RCA and drug eluting stent with a, using a drug eluting stent with a 4.5 non compliant balloon, post dilation, left main has a stent, left heart cath, and Pella is also being done. So we have significant obstructive CAD diagnosed by diagnostic cardiac cath, August 2 of this year. So, I don't know that I don't have the date on here but this one was done. But it was after the second. So, unless something's documented saying that anything changed or that that imaging wasn't good. We're not going to code for that. And then I have the left heart cath. Our diagnosis codes are I 25.119 because I have unspecified Angela. And then I also have that are 94.39 for that abnormal stress test. Jump over to the important words. And then we have moderate sedation. This physician documented that it was provided by him or her patient was continually face to face monitor by an independent trained observer are in ratchet. I changed her name to nurse ratchet those of you that are old enough know who I'm talking about. Total interest service moderate moderate sedation time of 93 minutes so I have the 99152. So coming down here. They accessed to the left femoral artery sheath was incrementally upsized to a 14 French and Pella. After they exchange over the pigtail catheter. Then did a heparin bolus ACT was maintained. During the procedure pigtail catheter was then used to reform the left heart cath and enter cavitary pressure measurement. The pigtail catheter was exchanged for impella left ventricular assist device so we place an impella. So our code here is the 33990. Normal flow augmentation waveforms were obtained patient remained electrically stable. Let's see here about that jr for guide catheter was used to perform right coronary angiography so again we're over here in the right corner. Distal RCA pre dilation balloon angioplasty of the subtotal occlusion of the RCA occlusion was performed. Repeat angiography was done a 3.5 shockwave CT lithotripsy balloon was on the calcified osteo RCA eight shock series was required to achieve that balloon. So our temporary code is 0715 T. Keep in mind that is an add on code so we had to do something besides that. Repeat angiography was performed, and then they placed a 4.0 18 millimeter drug eluting stent across the ostium of the RCA. And that was fully expanded, so I have the 92928. Then they went and did angiography of the left coronary, and they did do non selective route angiography, but again, there was a previous one. So, I don't have enough information here to tell me that they needed to do that by itself. BMI BMW guidewire was then put in the distal LAD drug eluting stent was deployed across the left main stenosis to ATM expansion. Multiple stents that are in the left main are only coded once. Repeat angiography was performed, that's all included all these follow up balloons are included. This gives our findings, left main the lesion underwent a successful drug eluting stent LAD has mild diffuse disease, less circumflex has mild disease. Right coronary is the dominant artery and there was a 95 RCA stenosis that underwent a successful drug eluting stent. And then of course we also have that lithotripsy. So, I have the 9928 RC 0715 t 33990 for the Apollo, we don't code. When they remove the same day you don't code the removal and in the same session. You only code, the insertion. Again, I have that moderate sedation, and then my diagnosis is I 25.119, because that Angela was not specified. Okay, case number seven chest pain are 7.9 we'll see if that stays and abnormal stress echo are 93.1. This one came through the femoral artery again so down in the leg threaded that calf up into the aorta perform left coronary angiograms so they looked at the left circumflex LAD, then advanced to the right coronary ostium did more injections. This was exchanged for a six French pigtail. Which was advanced into the left ventricle where in diastolic pressure was obtained and left ventricular gram was performed. Again, very good documentation very clear that because of this they had to cross the aortic valve CPT code is 93458. Next we have whisper wire was passed to the distal portion of the post posterior descending artery, which is a branch. The catheter was introduced but it would not pass into the proximal mid portion of the bustle balloon was withdrawn and Viper wire was placed CSI at the rectum he was then perform with two passes made along the length of the mid to distal right coronary after this we were able to deploy a 2.5 drug eluding stent in the mid portion of the RCA. So now we have a stent and an atherectomy, we don't report the atherectomy and then the step separate we use this combo code, the 92933. So again, he's over here in the right coronary whisper wire was then passed the distal portion of the large marginal we primarily deployed. Oh, I'm sorry now we're over here on the left, because we're the marginals. So we're in the circumflex the marginals come off of their drug eluding step was placed so we have the 92928. I have my emails, I have my findings for my coronaries. I have my LV gram. And my atherectomy and stent and the RC. My final diagnosis was coronary artery disease with 80% RCA obstruction, which underwent successful atherectomy and stent. And then we had a subtotal LAD diagonal size BC distal vessel at its best. And we had to preserve LV systolic function. And we have the moderate sedation. I'm missing that should say LC on that ABC, that should say LC, because that's where the steps place. So we have 92933 for that stent and atherectomy the right corner 92928 with a 59, because these bundle. We're denoting that this was an LC, you could also use the 15, or one of the X modifiers instead of the 50. Then we have our heart count moderate sedation diagnosis of I 25.10 because we have very clear documentation that this patient has coronary artery disease. Final case. This one we have an acute non ST elevation myocardial infarction with cardiogenic shock with active chest pain. We also have an emergent right and left heart cath that is done. So this clearly is a situation where this and STEMI can be billed as an acute him up And then we have the patient brought to the cath lab so the first part they did a right heart cath. So again, they came up to the vehicle, we have the right atrial pressure so we're in atrium, the right ventricle pressure, which is down here. And then we have our pulmonary artery pressure. pulmonary hypertension with a markedly elevated wedge pressure and reduce cardiac index so I'm also giving the I 27.20 for diagnosis. Because I'm going by the findings. On the left heart cath. We have LV pressure aortic pressure that was consistent with that shock on pullback there was 34 peak to peak gradient with mild to moderate aortic stenosis. So again, I know they cross the valve I got plenty of information here showing me that they cross the belt. Then they also talked about mild mitral regurgitation. So now again, I'm charting here. We have to use the I08, I08.0 because we have aortic and mitral valve issues. And I don't know if they're rheumatic or non because it's not specified. If it's not specified you have multiple valve issues. The guidance in ICD 10 tells you you must use the I code. Now, if you want to take this back to your physician and get them to clarify, or you can find somewhere in the chart that it specifically states that they don't have that. Then by all means, code it that way. All right, we also have a rake root angiography and this one, so we have the 93567 which is our add on code to the left heart cath. And then they talk about the findings of the coronary angiography. There's a 99% osteostenosis. So we also know the patient has that CAD. So they also have I2510. They also talk about the stents that the patient has stents also. So that gives us the 95.5. Notice that there's instant race stenosis. So now we also have a T code for instant race stenosis. This was the first that I've seen it documented. So I'm going to use the A, which is initial. All right, so what is so he's found all this stuff out. So now what are we going to do? Well, they're going to do this intervention of the obtuse marginal. Lesion was predilated with a 2.5 by 12 trek balloon. Ivis was also performed of the left circumflex, because that's where the obtuse marginal is. Lesion was then sent in with a 2.75 Alpine drug loading stent. And lesion was then posted with a 3.0 track tapering stent. Remember, we only get doesn't matter how many stents in the main vessel, you only get to code one. So we have 92941 with the left circumflex. At this point, patient remain in cardiogenic shock. So then they place an intra aortic balloon pump percutaneously. I've coded that with the 33967. Swan GANS catheter was sewn in place and will be used for management. But we did that right heart cath. So we're not going to code this as a Swan GANS. Final impression, we have successful balloon and stent to the obtuse marginal guided by Ivis and then placement of that balloon pump. And then again, they mentioned that pulmonary hypertension from their findings. So our final codes of this, I have the 92941. Documentation does support this being an acute MI and not just a normal end STEMI. 93460, because I have right and left heart cath with coronaries, we've crossed the aortic valve. We have supravalvular aortography. We have that balloon pump insertion. We have that Ivis of the left circumflex. Our final diagnosis is end STEMI. We have the R57.0 for that shock. We have the T code for the instant stenosis. We have CAD. We have that, gosh, I need a vacation after this case. We have the mitral and aortic valve issues. And we also have pulmonary hypertension. All right. A couple of final thoughts. I'm actually running over on time. Again, with the questions, we will compile all of these. They'll be available on the Academy. I want to send a final reminder in case you've logged in a little late to the webcast. We no longer email these out. You can access the CEU through the Academy. You do have to launch the webcast and you do have to register for it. And then final note, Jamie Quimby will be doing an ICD-10 webcast on the 22nd. There are actually several changes for the cardiology section, as well as I believe she told me over 1,000 changes total in the book. Obviously, she's not going to cover all 1,000 of those, but she'll definitely cover the cardiology. October, we will not have a webcast because we have our main CV community conference. And so we will not do a webcast in October, but Michelle and I will be doing one on open heart procedures in early November. And then either at the end of November or early December, we'll do one on the final rule. And then, of course, we'll be doing our four-day boot camp in December. I appreciate all of your time, your patience with this new system, and we'll get it hammered out. You're going to love it. I see a lot of my colleagues are answering questions as I was broadcasting. Even the ones that were answered, I will still compile and we'll put all of that together. So thank you so much. Have a great weekend, great rest of your day, and guess welcome to fall, right? Have a great day.

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Jolene Bruder

Senior Coding Consultant

MedAxon

cardiac cath

PCI coding

coronary artery disease

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coding guidelines

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