Eliminate coronary procedure confusion
A patient arrives complaining of chest pain. The physician determines the patient has a coronary artery blockage. The physician can choose from several options for treating the patient, depending on exactly what is wrong.
Unfortunately for coders, translating an operative report into what a surgeon actually did is often difficult, says John F. Seccombe, MD, a cardiothoracic surgeon in Green Bay, Wis.
Anatomy and function of the heart
Before coders can even determine what a surgeon did, they need to understand the anatomy of the heart and blood vessels and how they work.
Think of the heart as two pumps working side-by-side. It consists of four chambers—two ventricles (lower chambers) and two atria (upper chambers). A wall of muscle called the septum separates the left and right atria and the left and right ventricles.
The left ventricle is the largest and strongest part of the heart. It pushes blood out through the atrial valve and into the rest of the body. The right ventricle pumps blood to the lungs and does very little work compared to the left ventricle, Seccombe says.
The coronary arteries are like a tree—a trunk with branches, he says. The aorta (the main blood supplier to the body) branches off into two main coronary blood vessels. These coronary arteries branch off into smaller arteries, which supply oxygen-rich blood to the heart muscle.
The aortic root is the beginning of the aorta. It begins at the aortic valve where the aorta attaches to the left ventricle.
The ascending aorta rises up from the heart and is approximately two inches long. The coronary arteries branch off the ascending aorta to supply the heart with blood.
The aortic arch curves over the heart, where it branches out to carry blood to the head, neck, and arms.
The descending thoracic aorta is located in the chest, but in traveling down the body. Its small branches supply blood to the ribs and some chest structures.
The abdominal aorta begins at the diaphragm, splitting to become the paired iliac arteries in the lower abdomen. Most of the major organs receive blood from branches of the abdominal aorta.
Minimally invasive procedures
A surgeon can use a stent to open a blockage with minimal invasion. The surgeon uses a catheter to open the blockage, and then removes the catheter. The surgeon the slides a stent into the occluded vessel, expands the balloon inside the stent, and removes that balloon, Seccombe says. The surgeon performs the procedure in a catheterization clinic.
Physician documentation should be very specific, identifying the artery in which a procedure is performed and any movement into another artery, says Betty Johnson, CPC, CPC-I, CPC-H, CPCD, CCS-P, PCS, CCP, CIC, RMC. Johnson is AAPC regional director, midwest. Use modifiers -LC (left circumflex), -LD (left anterior descending), and -RC (right coronary) to denote which artery the physician was in when he or she performed the procedure.
Stents can be either bare-metal or drug-eluting. Bare-metal stents can lead to restenosis, a repeat narrowing of the vessel, approximately 30% of the time, Johnson says. Although these stents do not cause another disease, they result in a controlled injury similar to a scar. Drug-eluting stents are coated with drugs to interfere with restenosis.
Coders in hospital outpatient facilities should report the following CPT® codes for non-drug eluting stents:
- 92980 for a single vessel
- +92981 for each additional vessel
Assign the following HCPCS codes when reporting placement of a drug-eluting stent in a hospital setting:
- G0290 for a single vessel
- G0291 for each additional vessel
Coronary artery bypass graft surgery (CABG) is the most commonly performed cardiovascular procedure, Seccombe says. Surgeons create new paths around blockages.
A surgeon must harvest a vein to perform a bypass. The surgeon can use either one long incision or multiple smaller incisions to remove a vein for the graft. Report CPT code 33508 (endoscopy, surgical, including video-assisted harvest of vein[s] for coronary artery bypass procedure) for endoscopic vein harvests. Coders should report the vein harvest in addition to the primary procedure.
Surgeons generally harvest the internal mammary artery or greater saphenous vein, Seccombe explains.
The surgeon uses anastomosis to attache the vein. Surgeons can use side-to-side anatomosis, in which they connect the side of a graft to the side of an artery. Surgeons may also use end-to-side anastomosis, in which the end of a graft connects to the side of the coronary artery.
Coders select a bypass code based on the number of vessels the surgeon bypassed, Seccombe says. If the surgeon bypassed one coronary artery with a venous graft, report CPT code 33510. Assign code 33511 for two coronary venous bypass grafts. CPT includes additional codes for three (33512), four (33513), five (33514), and six or more bypass grafts (33516).
Coders should report these codes only when a surgeon uses a venous graft. Therefore, surgeons must document which vessel or vessels they harvested for a graft.
If a surgeon harvested an artery and bypassed a single coronary artery, coders should report code 33533. Again, coders would choose the appropriate code (33533–33536) based on the number of arteries a surgeon bypasses, Seccombe says.
If a surgeon used both arterial and venous grafts, coders should report the appropriate arterial graft code and an add-on code (33517–33530) for the venous graft.
Surgeons can perform a CABG procedure on a beating heart or a motionless heart. They can also use a heart-lung machine for both beating and motionless hearts. However, this does not affect code assignment for the procedure.
Email your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at email@example.com.