Tagged with: Coding to New Heights, Medical Coding

Coding to New Heights Education Newsletter January 2019 Edition

Peak Health Solutions - Jan 30, 2019

Our Monthly Peak Coding Education Newsletter, Jan 2019 Edition! This month we'll discuss: Mitral Valve Disorders, Cross Walking CPT & PCS New Cardiac Devices, Cardiac Catheterization Coding In An Outpatient Facility, Cardiac Valves, New York Heart Association  Functional Classification System or CHF, Anticoagulant Vs Antithrombotic, and test your knowledge of Underdosing with this month's Code Puzzler! 

In This Issue

funny-documentation-fail-125X125-BFunny Documentation Fail

“The Lab Test Indicated Abnormal Lover Function"



Taking A Closer Look At Mitral Valve Disorders And How To Code Them

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP
Lead Educator

Before we dive into how to code Mitral Valve disorders let’s take a quick look at the disease process. Located on the left side of the heart between the left atrium and left ventricle, the mitral valve (also known as Bicuspid valve) is the most frequent location of a valve disorder. Valve disorders can be congenital (atresia) or acquired. Provider documentation may report terms such as stenosis, insufficiency, regurgitation, incompetence, and prolapse.

Insufficiency, regurgitation, and incompetence are all terms to describe the same thing – meaning that the valve doesn’t close completely and allows blood to flow backward into the previous chamber. If this is present the provider may state that a heart murmur was heard on physical exam. This murmur may be described as a mid-systolic click or a systolic murmur.

Stenosis means the valve opening is narrowed or malformed inhibiting the flow of blood out of the ventricle or atria. This causes the heart to work extra hard to move the blood through the stiff valve. Documentation may state symptoms of dyspnea on exertion, fatigue, palpitations, hemoptysis, or cyanosis.

Coding Clarification Tips

  • If documentation supports Mitral valve stenosis, unspecified mitral valve disease, or mitral valve failure ICD-10-CM presumes the disease is rheumatic unless specified otherwise by the provider and is coded I05.x.
  •  If documentation supports Mitral Valve Insufficiency, incompetence, or regurgitation ICD-10-CM presumes the disease is nonrheumatic and is coded I34.0.
  • However, if a patent has both stenosis and insufficiency, then both are presumed as rheumatic and are coded as I05.2.


“Cross Walking” CPT And PCS New Cardiac Devices

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

New this year for PCS and CPT this coming year “2019” are the leadless Pacemakers. This new technology has proved to decrease infection, clots, and other valve dysfunctions associated with traditional pacemakers.

First, let’s discuss the leadless pacemaker. The leadless pacemaker is a miniature sized battery and delivery system that is so tiny it can be fed through a catheter in the femoral vein and placed directly inside the right ventricle. As it is deployed into the right ventricle, it is “screwed” into the muscle tissue at the base of the heart. This device can be monitored externally just like the older pacemakers.

ICD-10-PCS-image-300X168In CPT this procedure is coded 33274 Transcatheter insertion or replacement of permanent leadless pacemaker right ventricle, including imaging guidance. This procedure code can be found by indexing Pacemaker, Heart and then Permanent Leadless, Ventricular, and finally with sub-term Insertion.

In PCS this procedure is coded 02HK3NZ. Found by indexing Insertion of device in, then once in the PCS table choose body part value K for right ventricle, approach value P for percutaneous, and device value N for intracardiac pacemaker, with qualifier Z to complete the code.

Now for the wireless pulmonary artery pressure sensor. This device is used to monitor patients with class III heart failure. These classes will be discussed later in this newsletter in the CDI Corner. Once in the Cath Lab a catheter is fed through left femoral vein and a guidewire is placed in the left pulmonary artery. The device is guided up the guidewire and placed in the left pulmonary artery. In the picture below - the two little wire looking attachments on either end of the device holds the sensor in place. Typically, the left pulmonary artery is used as it is closest to the location used to externally monitor the patient. This procedure has significantly reduced CHF 30-day readmission rates by 25%!

Pacemaker-imageIn CPT this procedure is coded 33289 Transcatheter implantation of a wireless pulmonary artery pressure sensor for long term hemodynamic monitoring, including deployment and calibration of the sensor, right heart catheterization, selective pulmonary catheterization. This procedure code can be found by indexing Pulmonary Artery, pressure sensor, insertion.

In PCS this procedure is coded 02HR30Z. Found by indexing Insertion of device in, then once in the PCS table choose body part value T for left pulmonary artery, approach value 3 for percutaneous, and device value 0 for monitoring device, pressure sensor and qualifier Z to round out the code.


Locate the following words in any direction (across, downwards, diagonally)

Aortic Arch
Right Atrium



nuts-and-bolts-graphicCardiac Catheterization Nuts & Bolts Of Coding In An Outpatient Facility

Submitted by Guest Author Peggy Hapner, RHIA, CCS, CASCC

Cardiac catheterization procedures are commonly performed in the hospital outpatient setting in many facilities. Understanding these procedures and how to break them down is key in assigning the correct HCPCS/CPT code(s) to report the services. First, we need to understand what cardiac catheterization is: it is a non-surgical diagnostic procedure that includes the advancing of catheters into the ventricles of the heart, bypass grafts and/or coronary arteries. The procedure includes the insertion, positioning and repositioning (if needed) of the catheters into the vascular system. Also included in the procedure is the recording of the intracardiac/intravascular pressure(s) and the final evaluation and report of the Cath.

The Cardiac Cath codes are used to report two types of cardiac catheterizations; those with are performed for congenital anomalies and those performed for all other heart-related conditions. The Cardiac Cath can be performed on the left or right side of the heart or both sides. The more common of the two is the left-sided heart cath. Left-sided cardiac catheterization advances a catheter into the left side of the heart through the aortic valve. Contrast will be given to the patient so that the cardiologists may identify blockages in the blood vessels. Performance of the mitral and aortic valves along with coronary arteries are evaluated. Other procedures that may be performed during the left-sided Cardiac Cath are: ventriculography (to check the pumping function of the heart); coronary angiography (to visualize the coronary arteries) and angioplasty (this can be performed with or without stent insertion). Left-sided Cardiac Cath’s are reported with CPT codes 93452, 93458 and 93459.

Right-sided cardiac catheterization advances a catheter through a vein as opposed to an artery as in a left-sided catheterization. Measurements are taken of the right atrium, right ventricle, and pulmonary arteries and estimate the cardiac output (amount of blood that flows from the heart each minute). Right-sided Cardiac Cath’s are usually performed on very ill patients to detect abnormal blood flow in the heart. Right-sided Cardiac Cath codes are assigned to CPT codes 93451, 93456 and 93457.

Injection procedures for cardiac catheterizations are add on codes that describe the injections performed for angiography. There are currently three codes that describe these injections that are used for non-congenital Cardiac Cath’s. CPT code 93566 is assigned for the injection procedure of right ventricular or right atrial angiography; CPT code 93567 is assigned for supravalvular aortography and 93568 is used for pulmonary angiography injection procedure. Left Cardiac Cath’s include the supervision and interpretation and intraprocedural injection(s) for left ventriculography.

CPT codes 93453, 93460 and 93461 are used to report a combination of right sided and left sided Cardiac Cath’s. Congenital Cardiac Cath’s are assigned to CPT codes 93530-93533. With the congenital Cardiac Cath’s there is some add on codes to report the injection procedures for angiography; 93563 is assigned for the coronary angiography, 93564 for the bypass graft angiography and 93565 for the left ventricular or left atrial angiography. It is important to note that these add on codes are for congenital Cardiac Cath’s only.

What coders must identify before assigning a code for Cardiac Cath procedures is to determine the type of heart catheterization performed and to ensure that all the procedures described in the documentation are supported by the chosen code. When in doubt of the documentation provided, your best source for clarification is the Cardiologist who performed the procedure.

E/M ProFee
Submitted by Heather Saunders, CPC, CEDC, CEMC, CHCAS, CHCA
Pro-Fee Lead Auditor

Anatomy Feature

Cardiac Valves

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educato

Consider the cardiac valves as one-way doors throughout the heart. Each door or leaflet opens and closes in a symbiotic dance pushing life-giving blood throughout the whole body. Picture this as you look over the diagram below. Each valve has 3 flaps (known as tricuspid) except for the mitral valve which has 2 flaps (known as bicuspid). When one of these doors doesn’t close all the way or is malformed at birth, the patient starts to experience shortness of breath, fatigue, palpitations, dizziness, and chest pain to name a few. 

Anatomy-Feature-image-1 Anatomy-Feature-image-2


CDI Corner

CDI-Corner-image-170X170New York Heart Association Functional Classification System For CHF

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

Have you noticed provider documentation stating heart failure type 3 or the like? The provider is referring to NYHA’s Heart Failure classification system. This system serves as an assessment tool to measure the functional status or decompensation of the patient. The placement of pulmonary artery pressure sensor devices (discussed earlier) is based on this criterion.

The NYHA classes are:

Class 1 No limitations. Ordinary physical activity does not cause undue fatigue, dyspnea or palpitations (asymptomatic LV dysfunction). 
Class 2 Slight limitation of physical activity. Ordinary physical activity results in fatigue, palpitation, dyspnea or angina pectoris (mild CHF).
Class 3 Marked limitation of physical activity. Less than ordinary physical activity leads to symptoms (moderate CHF).
Class 4 Unable to carry on any physical activity without discomfort. Symptoms of CHF present at rest (severe CHF). Mostly bedbound patients.

As you can see the NYHA criteria is based on the patient’s symptoms. Therefore, the patient could move between classes depending on symptoms. The American College of Cardiology/American Heart Association also has a classification system with 4 levels as well using “stages” as the designation. Once a patient reaches a certain stage they do not go back.

The ACC/AHA stages are:

Stage A No objective evidence of cardiovascular disease. No symptoms and no limitation in ordinary physical activity.
Stage B Objective evidence of minimal cardiovascular disease. Mild symptoms and slight limitation during ordinary activity. Comfortable at rest.
Stage C Objective evidence of moderately severe cardiovascular disease. Marked limitation in activity due to symptoms, even during less-than-ordinary activity. Comfortable only at rest.
Stage D Objective evidence of severe cardiovascular disease. Severe limitations. Experiences symptoms even while at rest.

This information is provided to help clarify documentation of heart failure if it is written as a class or a stage. In the situation of different classes or stages being documented within the medical record, clarification will be necessary. This information could be referenced and used as a clinical indicator in a query to the provider. 


Pharmacology Spotlight

Anticoagulant Vs Antithrombotic

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

Used to treat
Atrial Fibrillation 
Current and History of DVT 
Current and history of PE
Prophylactic treatment for DVT Post Hip/Knee Replacement
Chronic CAD
Chronic PAD
Congenital Heart Defects

Anticoagulants, also known as “blood thinners,” slow down the process of making clots by inhibiting clotting factors. Antithrombotics, also known as antiplatelets, inhibit the enzymes that cause platelets to clump together. It is important to know what specific drug the patient is on in order to code the appropriate long-term use code. Long-term use of anticoagulants is coded Z79.01. Common anticoagulants are: Xarelto®, Eliquis®, Heparin®, Coumadin®, Arixtra®, and Pradaxa®. Long-term use of antithrombotics is coded Z79.02. Common antithrombotics are: Plavix®, Effient®, Brilinta®, Ticlid®, and Integrilin®.

Also, important to know, are the coding guideline for use of these codes. According to the ICD-10-CM Official Guidelines for Coding and Reporting, Z79.xx codes are assigned only when the patient is receiving a medication for an extended period of time as prophylaxis to prevent disease, to treat a chronic condition, or to treat a disease requiring a lengthy course of treatment. These codes are not assigned when the patient is on a medication for a brief period of time to treat an acute illness or injury.


The Code Puzzler


Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

In I-10 lingo “underdosing” occurs when a patient takes a lower amount of a prescription medicine or discontinues a prescription without their provider’s instruction. Coding guidance tells us that an underdosing code can never be assigned as a principal or first-listed diagnosis. In the situation of exacerbation or relapse of the condition for which the drug was prescribed occurs because of the reduction in medication the condition is sequenced before the underdosing code. If there are several drugs that the patient was not taking as they should then the coder must assign a code for each drug.

Code the following scenario: A patient was admitted to the hospital with acute exacerbation of COPD. Upon interviewing the patient, they admitted to taking Advair every other day to save money. 

ANSWER: Highlight the text below to see if you were correct! 
J44.1 Acute Exacerbation of COPD
T48.6X6A Underdosing of Antiasthmatics, initial encounter
Z91.120 Patient’s intentional underdosing of medication regimen due to financial hardship


Posted in: Coding to New Heights, Medical Coding

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