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CHAPTER 21
CARDIOVASCULAR SYSTEM
Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 1
Cardiovascular System
• CV coding may require codes from:
• Radiology
• Medicine
• Surgery
(Cont’d…)
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Slide 2
Cardiovascular System
(…Cont’d)
• Radiology: Diagnostic studies
• Medicine: Nonsurgical and
percutaneous
• Surgery: Open and percutaneous
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Slide 3
Cardiology Coding
Terminology
• Invasive: Enters body
– Example: Opening chest for removal,
tumor on heart or percutaneous placement
of catheter in artery
• Both Medicine and Surgery sections
contain invasive procedures
(Cont’d…)
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Slide 4
Cardiology Coding
Terminology
(…Cont’d)
• Noninvasive: Procedures that do not
break skin
– Example: Electrocardiogram
(Cont’d…)
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Slide 5
Cardiology Coding
Terminology
(…Cont’d)
• Electrophysiology
(EPS): Study of
electrical system
of heart
― Example: Study of
irregular heartbeat
(arrhythmia)
(Cont’d…)
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Slide 6
Cardiology Coding
Terminology
(…Cont’d)
• Nuclear Cardiology: Diagnostic and
treatment specialty, uses radioactive
substances for cardiac conditions
• Example: MRI
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Slide 7
Cardiovascular in Surgery Section
• Codes for procedures:
– Heart/Pericardium (33010-33999)
• Pacemakers, valve disorders
– Arteries/Veins (34001-37799)
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Slide 8
Heart/Pericardium
(33010-33999)
• Both percutaneous and open procedures
• Extensive notes throughout
• Frequent changes with medical advances
(Cont’d…)
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Slide 9
Heart/Pericardium
(33010-33999)
(…Cont’d)
• Examples of Heart/Pericardium
subheadings:
– Pericardium
– Cardiac Tumor
– Pacemaker or Cardioverter- Defibrillator
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Slide 10
Heart/Pericardium
Categories
• Pericardiocentesis: Percutaneous withdrawal
of fluid from pericardial space
• Excision of Cardiac Tumor: Open surgical
procedure for removal of tumor on heart
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Slide 11
Pacemaker or Pacing CardioverterDefibrillator (33202-33249)
• Devices that assist heart in electrical
function
Figure: 21.7 A, Single pacemaker. B, Dual chamber pacemaker. C, Biventricular pacemaker. (B from Christensen
BL, Kockrow ED: Adult Health Nursing, ed 5, St. Louis, 2006, Mosby.)
(Cont’d…)
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Slide 12
Pacemaker or Pacing CardioverterDefibrillator (33202-33249)
Figure: 21.5
(…Cont’d)
• Divided by where electrodes
placed, approach, and type
of service
• Pacemaker electrically
stimulates myocardium of
one or more chambers to
contract when heart fails to
do so
• Device can be temporary or
permanent
From Forbes CD, Jackson WF: Color Atlas
and Text of Clinical Medicine, ed 3, 2003,
Mosby.
(Cont’d…)
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Slide 13
Pacemaker or Pacing CardioverterDefibrillator (33202-33249)
Figure: 21.6
(…Cont’d)
• Placed:
– Atrium (single chamber)
– Ventricle (single chamber)
– Both (dual chamber)
– Biventricular, both
ventricles and right
atrium (uses 3 leads)
From Miller RD, editor: Miller's Anesthesia, ed 6,
Philadelphia, 2005, Churchill Livingstone.
(Cont’d…)
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Slide 14
Pacemaker or Pacing CardioverterDefibrillator (33202-33249)
(…Cont’d)
• Approach:
– Epicardial: Open procedure to place on
heart
– Transvenous: Through vein to place
in heart
(Cont’d…)
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Slide 15
Pacemaker or Pacing CardioverterDefibrillator (33202-33249)
(…Cont’d)
• Type of Service
– Initial placement or replacement
of all or part
– Number of leads placed
(Cont’d…)
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Slide 16
Pacemaker or Pacing CardioverterDefibrillator (33202-33249)
(…Cont’d)
• Patient record indicates revision or
replacement
• Usual follow-up period 90 days
(global period)
• Use -78 to indicate return to operating
room within global period
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Slide 17
Electrophysiologic
Operative Procedures (33250-33266)
• Surgeon repairs defect causing
abnormal rhythm
• Endoscopy Procedure
– Without CP
• Codes based on reason for procedure,
approach, and if CP bypass used
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Slide 18
Electrophysiologic Operative
Procedures (33250-33266)
• Chest opened to full view—Incision
– Cardiopulmonary (CP) bypass usually
used
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Slide 19
Patient-Activated Event
Recorder (33282, 33284)
• Also known as cardiac event recorder
or loop recorder
• Internal surgical implantation required
• Divided based on device being
implanted or removed
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Slide 20
Cardiac Valves (33400-33496)
• Divided on valve and CP bypass:
– Aortic
– Mitral
– Tricuspid
– Pulmonary
• Code descriptions all similar
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Slide 21
Coronary Artery Bypass Graft
• CABG performed
for coronary arteries
severely clogged
(atherosclerosis)
(Cont’d…)
Figure: 21.8A
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Slide 22
Coronary Artery Bypass
Figure: 21.9
(…Cont’d)
• Determine what was
used in repair:
– Vein (33510-33516)
– Artery (33533-33536)
– Both artery and vein
(33517-33523 and
33533-33536)
From Chabner DE: The Language of Medicine, ed
8, St. Louis, 2007, Saunders.
(Cont’d…)
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Slide 23
Coronary Artery Bypass
(…Cont’d)
• Number of bypass grafts performed
and if vein and arterial grafts are used
– Example: Three venous grafts
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Slide 24
Venous Grafting Only for
Coronary Artery Bypass Graft
• Codes 33510-33516
– Divided based on number of grafts being placed
• Procurement of saphenous vein included in
procedure (not coded separately) when
retrieved through open incision
• Code + 33508 reported separately
– Endoscopic, surgical, video-assisted harvest of
vein(s)
– Add-on code, do not append -51
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Slide 25
Arterial Grafting (33533-33536)
• Divided based on number of grafts
• Right coronary artery (RCA) has two
branches
– Right marginal
– Right posterior descending (PDA)
• Left main coronary artery (LMCA) has seven
branches
1) Left anterior descending, 2) diagonal, 3) septal, 4)
circumflex (LCX), 5) obtuse marginal (OM), 6)
posterior descending, 7) posteriolateral
(Cont’d…)
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Slide 26
Arterial Grafting
(…Cont’d)
• Several codes (33542-33548) for myocardial
resection, repair of a ventricular septal
defect, and ventricular restoration
procedures
• Obtaining artery for grafting included in
codes, except:
– Procuring an upper extremity artery
(i.e., radial artery), coded separately (35600)
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Slide 27
Combined Arterial-Venous Grafting
• Codes 33517-33523
– Divided based on number of grafts
• Report combined arterial-venous procedures
with two codes:
– 1) appropriate combined arterial-venous graft code,
and
– 2) appropriate arterial graft code (33533-33536).
– The -51 modifier not used with these codes
(Cont’d…)
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Slide 28
Combined Arterial-Venous Grafting
(…Cont’d)
• Procuring saphenous vein included, if open retrieval
• Endoscopic harvest is reported with 33508
• If reoperation report with 33530
– No -51, add-on codes
• Never used alone
• Add-on codes always used with Arterial Grafting
codes (33533-33536)
• Arterial-Venous codes report only venous graft
portion of procedure
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Slide 29
Endovascular Repair of
Descending Thoracic Aorta
(33880-33891)
• Placement prostheses for repair of descending
thoracic aorta
• Synthetic aortic prostheses placed via catheter
• Less invasive than chest or abdominal incision
• Report fluoroscopic guidance separately, 7595675959
• Includes diagnostic imaging (pre- and
intraoperative)
• Stent-graft (endoprosthesis) reinforces weakened
area
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Slide 30
Arteries and Veins Subheading
(34001-37799)
• Only for noncoronary vessels
• Divided based on whether artery or vein used
– Example: Different codes for embolectomy,
depending on artery or vein
• Codes describe excision of acquired
thrombus or congenital thrombus of an
artery or vein
• Thrombus, aggregation of blood factors
frequently causing vascular obstruction at
the point of formation
(Cont’d…)
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Slide 31
Arteries and Veins
(34001-37799)
Figure: 21.14
(…Cont’d)
• Catheters placed into
vessels for monitoring,
removal, repair
• Using nonselective or
selective catheter
placement
From Roberts JR, Hedges JR, editors: Clinical
Procedures in Emergency Medicine, ed 4,
Philadelphia, 2004, Saunders.
(Cont’d…)
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Slide 32
Arteries and Veins
(34001-37799)
(…Cont’d)
• Nonselective: Direct placement without
further manipulation
• Selective: Place and then manipulate
into further order(s)
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Slide 33
Catheter Placement Example
• Nonselective: 36000, Introduction of
needle into vein
• Selective: 36012, Placement of catheter
into second order venous system
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Slide 34
Vascular Families Are Like a Tree
• Main branch—first order (tree trunk)
• Second order branch (tree limb)
• Third order branch (tree branch)
• Appendix L, CPT, Vascular Families
– Lists first, second, third, and beyond third
order branches
– Assumption that starting point is
catheterization of aorta
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Slide 35
Brachiocephalic Vascular Family
• Report farthest
extent of catheter
placement in a
vascular family
Figure: 21.15
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Slide 36
Embolectomy and
Thrombectomy (34001-34490)
• Embolus: Dislodged thrombus
• Thrombus: Mass of material in vessel,
in place of formation
• Balloon removal: Threaded into vessel,
inflated under mass, pulled out with
mass
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Slide 37
Embolectomy
• Removal of embolus
Figure: 21.16
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Slide 38
Venous Reconstruction
(34501-34530)
• Types of repair:
– Valve of femoral vein
– Vena cava
– Saphenopopliteal vein anastomosis
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Slide 39
Aneurysm
• Aneurysm: ballooned or weakened area of vessel
• To select the correct code, check the operative
report for:
– Type of prosthesis
– Location of aneurysm
– Any additional services to facilitate placement of endograft
– Whether open artery access was performed, and if so, was
conduit created
– Whether open repair was required
(Cont’d…)
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Slide 40
Aneurysm
(…Cont’d)
• Repair by removal, bypass, or coil
placement
• Coil placement: Tiny, flexible, platinum coil
pushed into aneurysm and forms “ball” to
obstruct blood flow into aneurysm
• Endovascular repair (34800-34900)
from inside vessel
• Direct (35001-35152) from outside vessel
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Slide 41
Endovascular Repair of
Abdominal Aortic Aneurysm
• 34800-34834
• Extensive notes preceding codes—“must
reading”
• Uses fluoroscopic guidance report Radiology
75952 or 75953
• Includes access, catheter manipulation,
balloon angioplasty, stent placement, site
closure
• Other procedures performed at same time
are coded separately
• Verify bundled codes in CCI edits
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Slide 42
Endovascular Repair of Iliac
Aneurysm (34900)
• Extensive notes before codes
• Uses fluoroscopic guidance (75954)
• Includes positioning, deployment of
stent or balloon angioplasty
• Report separately
– Open femoral or iliac artery exposure
– Introduction of guidewires or catheters
– Extensive artery repair or replacement
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Slide 43
Repair Arteriovenous Fistula
(35180-35190)
• Abnormal passage
• Divided based on fistula type:
– Congenital
– Acquired/Traumatic
– By site
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Slide 44
Angioplasty and
Atherectomy (35450-35476)
• Open or percutaneous by vessel
• Transluminal angioplasty: Catheter
passed into vessel and stretched
– Code per vessel
– Stent placement reported separately
– Code imaging separately
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Slide 45
Noncoronary Bypass Grafts
(35500-35671)
• Divided by:
– Vein
– In-Situ Veins
(veins repaired in their original place)
– Other than Vein
• Coded according to the beginning and ending
vessels of the graft and vein used for the graft
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Slide 46
Bypass Graft, Vein
• Code by type of graft and vessels being
used to bypass
– Example: 35506, Bypass graft, with vein;
carotid-subclavian or subclavian-carotid
– Graft attached to carotid and to subclavian,
bypassing a defect of subclavian
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Slide 47
Vascular Injection
Procedures (36000-36522)
• Divided into:
– Intravenous
– Intra-Arterial—Intra-Aortic
– Venous
(Cont’d…)
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Slide 48
Vascular Injection
Procedures (36000-36522)
(…Cont’d)
• Used for many procedures, includes:
– Local anesthesia
– Introduction of needle
– Catheter
– Injection of contrast material
– Pre- and post-operative care
• Example: Injection of an opaque substance
for venography
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Slide 49
Transcatheter Procedures
(37184-37216)
Arterial mechanical thrombectomy (3718437186)
• Removal arterial thrombus by mechanical
device
• Used to report a variety of transcatheter
procedures
Venous mechanical thrombectomy (37187,
37188)
• Removal venous thrombus by means of a
mechanical device
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Slide 50
Cardiovascular in Medicine
Section
• Services can be:
– Invasive or noninvasive
– Diagnostic or therapeutic
(Cont’d…)
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Slide 51
Cardiovascular in Medicine
Section
(…Cont’d)
• Subheadings:
– Therapeutic Services and Procedures
– Cardiography
– Implantable and Wearable Cardiac Device
Evaluations
– Echocardiography
(Cont’d…)
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Slide 52
CV in Medicine Section
(…Cont’d)
• Cardiac Catheterization
• Intracardiac Electrophysiologic (EP)
Procedures/Studies
• Peripheral Arterial Disease (PAD)
Rehabilitation
• Noninvasive Physiologic Studies and
Procedures
• Other Procedures
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Slide 53
Therapeutic Services
(92950-92998)
• Types of services:
– Cardioversion
– Infusions
– Thrombolysis
– Catheter placement
(Cont’d…)
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Slide 54
Therapeutic Services
(92950-92998)
(…Cont’d)
• Many groups of codes are divided by:
– Method (e.g., balloon, blade)
– Location (e.g., aortic or mitral valve)
– Number (e.g., single or multiple vessels)
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Slide 55
Cardiography (93000-93278)
• Types of service:
– Stress tests
Figure: 21.22
Figure: 21.24
– Holter monitor
From Young AP, Proctor DB:
Kinn's The Medical Assistant,
ed 10, St. Louis, 2007,
Saunders.
Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
From Forbes CD, Jackson WF:
Color Atlas and Text of Clinical
Medicine, ed 3, 2003, Mosby.
Slide 56
Cardiography (93000-93278)
• Electrocardiogram
• Separate codes for global procedure
and components (professional and
technical)
– See 93000, 93005, 93010
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Slide 57
Holter Report
• Used to identify
cardiac arrhythmias
Figure: 21.26
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Slide 58
Implantable and Wearable
Cardiac Device Evaluations
(93279-93299)
• New codes in 2009
• Category notes include definitions and
instructions
• Extensive notes
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Slide 59
Echocardiography
(93303-93352)
Figure: 21.27
• Noninvasive diagnostic procedure: Ultrasound
detects presence of cardiac or vascular disease
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Slide 60
Cardiac Catheterization
(93451-93568)
• Used to identify valve disorders,
abnormal blood flow
• Many bundled services in
catheterization codes
(Cont’d…)
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Slide 61
Cardiac Catheterization
(93451-93568)
(…Cont’d)
• Example:
– Introduction
– Positioning/Repositioning of catheter
– Pressure readings inside heart or vessels
– Blood samples
– Rest/Exercise studies
– Final evaluation and report
• Many codes -51 exempt
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Slide 62
Three Components of Coding
Cardiac Catheterization
• Placement of catheter
• Injection
• Imaging supervision, interpretation, and report
• All 3 components are included in most catheterization codes
• Some cardiac catheterization codes require an
imaging/injection code 93530-93533, cath for congenital
anomalies require 93563 or 93564 (imaging/injection)
From Chabner DE: The
Language of Medicine, ed
8, St. Louis, 2007,
Saunders.
Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 63
Intracoronary Brachytherapy
(92974)
• New procedure, uses
radioactive substances
to destroy restenosis
of coronary vessel
• Patients have had stent
placed in coronary vessel
From Zipes DP, editor: Braunwald's
Heart Disease, ed 7, Philadelphia,
2005, Saunders
• Stent “restenosis”
(reformation of plaque)
(Cont’d…)
Figure: 21.29
Brachytherapy delivery system for
coronary artery stent restenosis
From Zipes DP, editor:
Braunwald's Heart Disease, ed 7,
Philadelphia, 2005, Saunders
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Slide 64
Intracoronary
Brachytherapy
(…Cont’d)
• Cardiologist: Places guidewire and
catheter
• Radiation oncologist: Places
radioactive elements
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Slide 65
Intracardiac Electrophysiologic
Procedures/Studies (93600- 93662)
• Services to diagnose and treat
conditions of electrical system of heart
• Tests involve placement of special
catheters into heart and cardiac
vessels for purpose of pacing and
recording intracardiac activity
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Slide 66
EP System of Heart
• Electrical conduction system
(Cont’d…)
Figure: 21.30
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Slide 67
EP System of Heart
(…Cont’d)
• Electrical recording codes divided
based on location of recording device
• Example: Bundle of His or right
ventricle
(Cont’d…)
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Slide 68
EP System of Heart
(…Cont’d)
• Pacing: Temporary pacing to stabilize
beating of heart
• Example: Intraventricular or intraarterial pacing
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Slide 69
Peripheral Arterial Disease
(PAD) Rehabilitation (93668)
• Rehabilitation sessions: 45-60 minutes
• Use of motorized treadmill/track to
build patient’s CV endurance
• Supervised by exercise physiologist
or nurse
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Slide 70
Noninvasive Physiologic Studies
and Procedures (93701-93790)
• Category contains codes for services
such as:
– Plethysmography: Recordings of changes
in size of body part when blood passes
through it
(Cont’d…)
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Slide 71
Noninvasive Physiologic Studies
and Procedures (93701-93790)
(…Cont’d)
• Electronic Analysis: Checks electronic
function of devices, such as
pacemakers
(Cont’d…)
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Slide 72
Noninvasive Physiologic Studies
and Procedures (93701-93790)
(…Cont’d)
• Ambulatory Blood
Pressure Monitoring:
Outpatient basis over
24-hour period
• Thermograms: Visual
recordings of
temperature of body
From Forbes CD, Jackson WF: Color Atlas and
Text of Clinical Medicine, ed 3, 2003, Mosby.
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Slide 73
Cardiovascular
in Radiology Section
• Divided complete procedures into
two components: Technical and
Professional
(Cont’d…)
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Slide 74
Cardiovascular
in Radiology Section
(…Cont’d)
• Radiology Section, Heart (75557-75574),
and Aorta/Arteries (75600-75791)
subsections
(Cont’d…)
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Cardiovascular
in Radiology Section
(…Cont’d)
• Example: Angiography
– Technical component angiography—
remains in Radiology Section
– Professional component injection—moved
to Surgery Section
(Cont’d…)
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Cardiovascular
in Radiology Section
(…Cont’d)
• Complete angiography requires
radiology code and surgery code
• Reflects common practice of
cardiologist’s performing injection and
radiologist’s performing angiography
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Contrast Material
• Often radiologic procedures use
contrast material to improve image
• Many codes have contrast material
bundled into service
– “With contrast” or “with or without
contrast”
• Only injected contrast qualifies
(Cont’d…)
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Contrast Material
(…Cont’d)
• Contrast not included in description,
used in procedure; code both contrast
material and injection separately
• Physician performs injection procedure
in hospital outpatient department; use
-26 for professional component only
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A Component Coding
Example
• Two physicians (cardiologist and
radiologist from same facility) perform
angiography of third order
brachiocephalic artery with contrast
• Cardiologist placing catheter (36217)—
Surgery Section
(Cont’d…)
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A Component Coding
Example
(…Cont’d)
• Radiologist performs angiography
(75658), Radiology Section
• Supply of contrast material (99070),
Medicine Section
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Conclusion
CHAPTER 21
CARDIOVASCULAR SYSTEM
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