Chapter 4 (p. 105) Surgery
CARDIOVASCULAR
Cardiovascular System
Codes categorized by
1) body part involved
2) procedure performed
Vascular Injection Procedures
Intra-Arterial/Intra-Aortic Injections
Intravenous Injections
Inserting a Pacemaker (or Pulse Generator) or Pacing
Cardioverter-Defibrillator (33202-33249)
The pacemaker device is being inserted percutaneously
and Leads are being attached transvenously (thru
the circulatory system to get into the heart).
Another way to attach leads is epicardially (upon
the surface of the heart) which is usually not done
locally unless it's an emergency situation.
Single Chamber Devices: lead into the Rt atrium or Rt
ventricle. The sinoatrial node and Bundle of His
are located here. Need electrical stimulation to
generate a pulse.
Dual Chamber Devices: A lead into the Rt atrium and
the Rt ventricle.
Biventricular Devices: A lead into both ventricles.
Crossing the coronary sinus (see pg. 189 picture).
Used in pts with Congestive Heart Failure (CHF).
If the Op Rpt talks about going through or crossing the
coronary sinus, they are probably putting a lead to
the left ventricle. A more involved procedure.
When inserting Implantable cardioverter defibrillator
devices you need to ask the following when coding:




Was the electrode(s) inserted into the atrium,
ventricle, ore both?
Was a single lead inserted? Dual leads? Multiple
leads?
Did the procedure involve inserting, replacing, or
repositioning the device(s)?
Did the surgeon use the epicardial or transvenous
approach?
The Op Rpt may say after inserting a defibrillator that
they've converted the pt out of V-Fib. This is
intentional to test to see if the device is working.
Do not code the V-Fib as a Dx if this is the only place
it is mentioned.
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Coronary Artery Bypass Grafting (CABG)
(For Physician Coding)
Count the number of location on Coronary Artery being
bypassed.
2 Techniques for bypass
--Saphenous vein (or other vein) out of leg, reverse
it to act as artery and connect it to the Aorta and
then to the coronary artery. (33510-16)
--Internal Mammary or Thoracic Arteries pulled
forward. (33533-48)
These are coded based on the number of anastemoses
are being made with the graft(s).
If doing BOTH arterial and venous bypass graft... code
the arterial portion (33533-48) and then use ADDON code (33517-23)
If doing venous graft only, these other 2 areas are
excluded.
Ex: We did a bypass: RT, internal mammary artery
bypass, single. Also did an aortocoronary bypass
with a saphenous vein, bypassing to LAD, and to the
obtuse marginal vein (branch).
33533 + 33518 (2 locations)
Harvesting of saphenous vein graft is included in the
Venous and Combination code set. If vein comes
from elsewhere (leg or upper extremities)
(35500, 35572) Add-on codes for harvesting vessel for
CABG.
Know:
 Arterial and Venous? Venous only? Arterial only?
 Code vein graft if other than saphenous vein
A redo on a CABG operation (> 1 month after the
original) is coded +33530 (at the end of the
combined A-V grafting codes. More complicated
than the original procedure. Do not code the
original procedure. Just the current CABG + redo
codes.
Bovine Arch: Aortic arch has only 2 major arteries
coming off it instead of 3. This changes the order of
the branches.
Contralateral study: Opposite side. Go up from below
to above the aorta, then come back down thru
aorta.
Ipsilateral study: Same side
Chapter 4 (p. 105) Surgery
CARDIOVASCULAR
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Interventional Radiology Procedures for
Cardiovascular Conditions
Imaging for remote access via catheters in order to
do imaging exams to visualize blockages.
= Minimum of 2 codes
(See Appendix L for classification guidance of vascular
families when coding injecting contrast into veins
and arteries.)
Arteriovenous Fistulas and Grafts
Most desirable method for hemodialysis access
 less likely to clot
 less likely to become infected
 last longer
The surgeon connects artery to vein. Arterial pressure
toughens up the vein walls & they thicken. Good for
dialysis needles.
Angiography (2 codes)
 Imaging portion: Radiology. i.e., supervision and
interpretation (S&I) of images These codes are
assigned based on the vessels imaged, not the
vessels catheterized. Use notes to see if CPT
codes are bundled together w/S&I codes or not.
 Surgical portion: Inserting catheter i.e., injection
Fistula: take longer to heal.
 Vein Transposition: coded according to vein
used. May be donor vein or autologous
 Direct Anastomosis (Cimino): Side-by-side
connection (36821)
of contrast, implant of device, removal of stricture
w/angioplasty balloon
Imaging codes are often chargemaster driven (hosp)
Catheterization part is more challenging:
Know Catheter Placement
 Nonselective: The catheter is not advanced beyond
the access site.
a) the vascular catheter is left in the vessel it
punctured and not advanced any further; or
b) the vascular catheter is advanced into the aorta
and not beyond;
 Selective: catheter placement is moved beyond the
vessel punctured or beyond the aorta.
a) Have to know that the catheter was placed into
Aorta and moved past it and know where the
catheter tip ended up.
Arterial vascular family: arteries fed by a primary
branch
Venous vascular family: veins that flow into a primary
branch
Coding Guidelines instruct (p. 110)
 to code to the highest-order catheter placement
within a vascular family (smallest branch);
 Each vascular family catheterized is coded
separately (if catheter backed out and moved to
another family);
 a code for nonselective catheter placement should
not be assigned in addition to a selective catheter
placement code unless there are multiple accesses
(punctures).
Graft: Harvesting vein (autogenic)
 If veins are too small or too far apart or not
enough time to perform procedure for fistula,
an AV Graft (36825-36830) may be performed.
 Advantage: Quicker to heal.
 Disadvantages: produce clots or become
infected, may need revision(s).
Complications of AV Fistulas & Grafts (p. 112)
 Clotting
 Obstruction
 Narrowing of the access
Corrections of Grafts
 Stenosis: angioplasty, stent placement,
thrombectomy
 Can do balloon angioplasty to enlarge (35476)
 Thrombectomy can be done with or w/out
revision (open) (36831, 32, 33)
 Revisions: The fistula or graft may need fixing
 Percutaneous thrombectomy may be via
pharmaceutical or mechanical (36870)
o + punctures of Artery and Vein, each
coded (36147, 36148)
 Venous anastomostic stenosis (are common)
often treated with balloon angioplasties to
restore patency and flow. (35476 Transluminal
balloon angioplasty, percutaneous, venous)
Chapter 4 (p. 105) Surgery
CARDIOVASCULAR
Central Venous Access Procedures
CVAD - Central Venous Access Device for frequent
access to bloodstream:
 Antibiotics, Chemotherapy
 Fluids & Nutritional compounds
 Tranfusion of blood products
 Multiple blood draws for testing
Removals are usually done in physician office.
Know:
1) Did catheter end in central vein?
2) Was access point central or peripheral?
3) Was catheter tunneled or not?
4) Is there a Pump or Port?
5) Age of Pt?
Peripherally Inserted Central Catheter (PICC Line 36568)
Ex: 5 yr old, central cath inserted thru cephalic vein,
terminates in brachiocephalic (inominate)
1. central, peripherally inserted = 36569
Endovascular Revascularization (Open/Percutaneous,
Transcatheter) (p. 115)
Peripheral artery disease (PAD): Plaque builds up in
arteries of limbs.
Balloon angioplasty w/or w/out stents
 by site
 by procedures performed (stent in, or
atherectomy -plaque out)
Coding Guidelines include:
 Only 1 code from family reported for each lower
extemity vessel--code to the highest severity, most
intense thing being done.
 Tx of multiple territories in same leg, one primary
low extremity coce is used for each territory
treated.
 Use add-on codes for additional vessels treated
w/in the territory
 If a lesion extends across the margins of one vessel
vascular teritory to another but can be opened
w/single therapy, the single code should be
reported (overlapping stents across the blockage,
this is stenting 1 vessel - single therapy)
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Primary: initial
Secondary: It's been done before
Ligation, Division, and Stripping of Saphenous Veins
Varicose veins (37718-37735). If veins are cut out or
tied off, there are collateral veins for circulation.