We have actually a few minutes for answering questions, and I know Sean has been keeping track of some of the questions. So, feel free to pull up 1 of the questions that have been posted. Sean. Yeah, thanks, Frank. So I've got a bunch of great questions. 1, 1, really interesting 1, which I was not aware of. And I, you know, Frank kind of mentioned earlier. There are some gray zones, and this may be something we'll have to talk about as a panel and certainly investigate more. Apparently, 1 of the respondents mentioned that CPT states that anomalous coronaries, PFO, MVP, which is mitral valve prolapse and bicuspid aortic valve. In the absence of other control heart disease are coded as non congenital. So, that's really interesting. I'd never heard that before. I can tell you. My take would be if the, if the valves specific to the valves, at least to mitral valve prolapse and bicuspid aortic valve, if they're dysfunctional. And the kid was born with them, and it's causing physiologic changes that we're having to cath and look about doing, at least consider doing an intervention or medical, even medical therapy. My opinion is that that would be a congenital lesion. That's what they're born with. And, you know, this is where the nuance of how we feel it comes into play. I would code it. I'm sorry. I would call it congenital mitral valve stenosis or regurgitation. Congenital aortic valve stenosis, I'll let the other people chime in, but my impression is that that is probably those are very common things. And what the CPT doesn't want the, you know, internal medicine physicians to do is if they're cathing somebody for coronaries and just incidentally find a normally functioning bicuspid aortic valve, which is very common. They don't want them to code that as a congenital path, but I think if the child has physiologic changes that are causing, you know, and I see my other, my co-worker members nodding their heads at that. So I would review that. PFO, though, I would probably agree is not congenital, I suppose, although that doesn't really, it's more of a, that's more of a semantics, because if we close it, it's the same, it's the same ASD closure code, PFO closure code. So that doesn't really matter. Hopefully no one's just capping people with PFOs and not doing anything about it. I think that, I think in general, we agree with this, and it certainly is a gray area. I think that the alkapla, the anomalous coronaries, I mean, most people would have coded as an abnormal. I think it's interesting that when we first talked about normal, abnormal connections, where we're thinking of the, like you said, Sean, the Von Pragen way of looking at the segmental parts of the heart, right? The AV connection, the VA connection, but the anomalous coronary, it's an abnormal connection, but it's not part of those three segments, just like, like you said, like the isolated RPA off the PDA is similar because it's talking about distal to the great vessels. And so, but again, I think that in that realm of sort of the abnormal connection, I would put that in the category of abnormal. What do you guys think? I have, can you hear me? You're muted. So, do you hear me? Okay. Yeah, we can, we can hear you, Mark. Yeah. No, I, I would agree with a lot of things that Sean has already mentioned and Frank as well. And I think that the funny thing is, you know, it's hard to account for everything, but, you know, congenital is congenital, right? If it's something you were born with and it wasn't, and it ain't normal, that's kind of the way to think about it. You know, that may be a little bit of black and white. I would bet you there will still be some disagreement about that, but I would also bet that if you pulled a hundred pediatric cardiologists who happened to follow patients in their clinic that have bicuspid aortic valve disease, on a regular basis, albeit maybe not frequently, and who have patients with mitral valve prolapse, for instance, or who discover a patient who happens to have even anomalous right coronary artery from the pulmonary artery traveling maybe between the aorta and pulmonary artery. I think we would, anyway, I think we would say, if you had a hundred, I would think the far majority are still, or at least 75% or so, we're going to call those congenital. Maybe more than that, I could be even underestimating that, but I think that's where the rubber kind of meets the road with that, and certainly I would vote in that direction. Chris, you're on. I was just going to add to that, that maybe one of the other pieces to the discussion is if there's pathology associated with it, and that's what Sean was getting at, right? Bicuspid aortic valve, very common, and a lot of those can be undiagnosed because there's no pathology. But if we're following somebody in our clinic, certainly if we're cathing somebody that has significant aortic stenosis associated with a bicuspid valve or insufficiency associated with it, we're ballooning a valve like that, we're treating it. There's pathology there, and that's a different story than the benign, just incidental finding sort of, or the one without any pathology. Same thing for an anomalous coronary, perhaps, when we talk about some of those that have pathology associated with it, when we're talking about doing something to it. So maybe that's just another piece to the nuance that we can add in, and if we are doing our notes, again, getting into one of the things that Guru said and advised us all is documentation, documentation, documentation. Help your team out, help your coders out there, your team members. So code in there, whether you want to say bicuspid aortic valve or not, fine, but say, you know, patients presented to the cath lab because of severe aortic stenosis and need for balloon aortic valvuloplasty, or whatever, or insufficiency leading to left heart failure, but give them some information, give them some justification to help you out, so. Great. So, Sean, are there another question? We have, actually, we're at five o'clock, but maybe we'll give a couple of extra minutes for a pressing question. If not, I can ask you one, Sean, where you talked about normal connections and dextrocardia. Can you talk a little bit about that, just to clarify? That's the one that Alan's going to bring up, and again, this is a great question. I'm kind of mad at myself. I hadn't thought about this. Frank asked me, sent me a private message saying, what would you do for somebody with situs inversus totalus, and, you know, it kind of goes back to what I was saying also initially is, you know, I think we can overthink some of these things, and so, you know, yes, they may have technically normal alignments, but I mean, literally, situs inversus means everything's backwards, right? It means everything's inverted in the body, so, you know, I don't think it's a stretch to say that that's an abnormal connection. Everything's mirror imaged and capping them. You know, another fundamental thing that I think people would like to get is, you know, these codes are based on the work done, and so it's definitely different code capping a kiddo as SLS, you know, or situs inversus. Everything's backwards, like I said, right? So we're not doing the exact same work as what you would do with somebody like a transplanted heart or a completely normal native connection. So my opinion, I would bill that as a congenital abnormal connection. Any different? Nicole, your hands up is up. Sorry, my hands up, but it's not about that. I actually agree with with with what John just said. I would do citus inversus totalis is much harder than someone who's got normal, normal everything. And I think I would I would also do that as abnormal connections. I wanted to clarify something from the cohort section that I didn't put in my slide, and I'll add it to the slides before they go into the into the cloud for people to see in the future, which is that if you do an intervention on the subclavian or 1 of the branches or stented, you bill separately for that intervention in the court case. So, if you have to balloon dilate through it into the left subclavian, you can bill for left subclavian artery dilation. You just need to document that you're doing. It wasn't clear. We are at 503, and I know that we all want to be respectful of people's time. So we'll end it here. I know that there are a few other questions that were posted and we'll gather that up and this is all recorded so that people actually can go look at this later on in the sky website. And so happy to answer questions that are posted to us and thank you again for joining us in this webinar. All right. Thanks everybody.

coding anomalies

cardiology procedures

congenital heart conditions

mitral valve prolapse

bicuspid aortic valve