Hi everybody. I would like to thank everybody for giving me the opportunity to present today. The topics that I'm going to be covering today are a couple. I will be focusing mostly on the intercalary extent codes, and I'm going to spend just a couple of slides on hybrid single ventricle procedure here, and that will create a segue for our p-extent codes, and that Jeremy is going to be presenting. I do not have any relevant disclosures. So the intercalary extent codes, this working group, we worked quite successfully to create some new intercalary extent codes that were introduced in 2021, and including the, in addition to the ballonatal septostomy codes, and this is going to be just a refresher of the intercalary extent code portion of those new codes. That includes the 33745, which is the transcatheter intracardiac shunt creation, the first shunt, 33746, which is the additional stent code. Here's the long descriptor for that. We don't need to go over the entire thing, but a couple of highlighted points here. The 33745 code is for intracardiac stent placement for congenital cardiac anomalies, and the reason I highlighted congenital cardiac anomalies is that it cannot be used, for example, if you stent the atrial septum in somebody who's non-congenital. I highlighted some examples that are here for the long descriptor. This will include the atrial septal stent, the fontan fenestration stents, the RVOT stents that I will show some example about, the mustard-sending warden baffles. They all come into intracardiac stent codes. The way we thought about it when we created these codes were, if you place a stent somewhere and if you have to move or displace, if it falls into the heart, whether it's upper chamber or the lower chamber, that means it is an intracardiac stent code. That's how we thought about this when the codes were created. This does include a diagnostic right and left heart catheterization. It does include stent delivery and any additional stent placed at the same location. Say, for example, sometimes we'll have to extend a stent, put a stent in a stent. It does include angioplasty at the same site. For example, we predilated the area before placing the stent. But what it does not include is angiography. Angiography, and we will come to that in the next few slides, is always additionally reportable as long as it is not road-mapping angiography, but angiography for diagnostic purposes. And angioplasty or any other intervention in a separate, distinct lesion can also be reported separately. And what I highlighted here, again, is some of these patients may be less than 4 kg and Dr. Ng is going to talk about modifiers, but a modifier 63 can be added to these intracardiac stent codes. I am putting in parentheses that unlike the balloonatal septostomy codes where the modifier is already included for these codes, a modifier 63 is reportable. In that example of the descriptors of what are considered typical examples of intracardiac stent codes, the one example that was not written there is pulmonary vein stent. But pulmonary vein stents are intracardiac stents which extend into the left atrium. So I just wanted to highlight that that is also a very common procedure that is done in a congenital lab, which is an example indeed of intracardiac stent. 33746 is the exact same thing but for the additional stent. It has to be in a distinct second location. As I mentioned, it cannot be a second stent in the same location. Just wanted to highlight that point. With that, let's go over a few examples. I have four or five examples here of typical intracardiac stents that we use in congenital heart disease. Here is an example of an infant who has got two stents in the left upper pulmonary vein and the left lower pulmonary vein. So the way we would code that is we would do 33745, which as I mentioned is the initial stent code. It does include diagnostic portion, ultrasound guided access and any angioplasty you may have performed at the same time. We could in addition report 93574, which is pulmonary vein angiography because diagnostic pulmonary vein angiography is not included in the initial stent code. And for the second stent that was placed in the left upper pulmonary vein, that would be a distinct second location. So that would be 33746. So this is a good example of intracardiac stent code for pulmonary veins. Moving on to intracardiac stent code for atrial septal stent. This is an example of a newborn baby who we stented the atrial septum in the first few hours of life. We created a communication between the right atrium shown here and the left atrium with the transseptal puncture. We dilated the atrial septum with a balloon followed by stent placement. Here we could grab all aspects of this procedure with just one code, 33745. It includes both the diagnostic right and left heart cath, ultrasound guided access as well as angioplasty at the same location. The third example I have is an example of RV2PA conduit stent or also known as proximal sano shunt. In this example, we have a catheter going through the right heart into the right ventricle and a wire through the RV2PA conduit. And as you can see here, there are two stents we have placed in the proximal RVOT conduit. One to extend the stent further into the right ventricle. And here again, we can use the intracardiac stent code 33745 even though we put place two stents. It was in the same location intended to extend the same stent and therefore we cannot code an additional stent. 33745 would cover for that, but we can code for angiography. So we can code 93566 for RV angiogram. I want to contrast this. If we had done a distal RV2PA conduit stent code, that would not classify as intracardiac stent code and that would fall into the group of pulmonary artery stent code because if that stent were to move, that would go into the PA. And Dr. Ringwald is going to talk about PA stents. The last example I have for intracardiac stent code is mustard baffle stenting. Mustards are the type of surgical procedure for transposition of great arteries where the SVC and IVC are baffled and connected to the left-sided ventricle. And in those patients, sometimes we, like in this example, they develop narrowings which needed balloon angioplasty and stent placement. In this particular patient, we did angiograms of the SVC and the IVC to diagnose the stenosis. We angioplasty the superior limb and then followed that up with stent placement with the superior and inferior limb of the mustard baffle, so the SVC portion and the IVC portion. And this would be built with 33745, again, for intracardiac stent placement, which would include the diagnostic cath and angioplasty as well, but it does not include angiography, so we can use 75827 for the SVC, 75825 for the IVC, and we add the second additional stent with 33746. I hope that is clear. I wanted to emphasize what Chris just mentioned, that accurate and proper documentation is extremely critical, and it really sets the way for building our builders and coders and makes their life easier for doing and helping us with all the right codes. And the example for how you can probably build for a SVC diagnostic angiogram, which is separate from road mapping angiogram, would be to use examples like this, like the patient was referred for further diagnostic cardiac catheterization to determine if intervention was needed. The cranial end of SVC was normal, therefore, and there were no decompressing veins, and just a few examples. Road map angiography, however, is included. So all those other angiograms that we do for proper stent positioning is included as part of the intervention, but the initial angiogram to diagnose the narrowing could be built separately. In the last couple of slides, I want to touch one common procedure that we've been doing more often in the cath lab these days, which is percutaneous stage 1 procedure for single ventricle. This often involves a newborn baby with a single ventricle physiology who gets a completely transcatheter percutaneous intervention, which includes a ductal stent, a stent in the PDA, to provide systemic blood flow. We often place fenestrated occluders or branch PA plugs in branch PAs to regulate pulmonary blood flow, and sometimes we have to do atrial septal stent, as shown in this example child. The way to code for this is you can always code for a diagnostic cath if you did one, so that would be 93597, abnormal connections. The stent in the ductus, and Jeremy is going to go over this, is going to be 33902. That is, PDA stents will be coded as PA stents in the setting of unilateral abnormal connection. But for the branch PA vascular plugs that we place, we would like to call them as basically plugging or arterial embolization of the arterial field. That will be done with 37242, which is arterial embolization code, and we'll code that twice, one for the right surgical field and one for the left surgical field. Again, in situations like this, using terms like fenestrated occluders where placed in the right and left pulmonary arteries to restrict pulmonary blood flow probably helps the coders rather than using terms like flow restrictors. If you did a atrial septal stent, of course, we can use a transcatheter intercutting stent code, and of course, you can add a modifier if the patient is less than 4 kgs. In contrast, if we did a hybrid stage 1, where the surgeon opens the chest for you in the cath lab and puts surgical PA bands and gives you access to the main pulmonary artery through which we sometimes place the ductal stent, then we build two separate ways. The surgeon himself reports a 3360, which is application of right and left pulmonary artery bands with a modifier 62 for a co-surgeon, which Dr. Ng is going to talk more about. And GV, as an interventional cardiologist, is going to build 33621, which is the insertion of a catheter for stent placement through a hybrid approach, but we add a modifier 62 for a co-surgeon, and we build 33902 for the PDA stent. And we can obviously add any angiography and any other procedures that can be done at the same time. I hope that helps and that clarifies some of the things that we did, and we'll be open for questions later. Thank you.

intercalary extent codes

hybrid single ventricle procedures

intracardiac stent creation

PDA stents

arterial embolization