I wanted to kind of go through some of the post-transplant biopsy codes because I feel like that that's been, we feel as a group that that's been an area that has some confusion with it and I think that Sean just set kind of a good stage for that in terms of when to use the congenital, when to use the non-congenital cath codes in association with these kids post-transplant. So I have no disclosures either. So in general, you have to look at what their fundamental cardiac disease is in terms of what you're doing for it. So if their fundamental disease is that of something that's acquired, right? So your cardiomyopathies that are acquired, myocarditis, things like that, those would be non-congenital. And we'll come back to these kind of cardiomyopathies that are genetic in their etiology. But anything that's sort of this acquired disease that you're doing a cath and a biopsy for, then you're going to use the non-congenital codes for that. So in this situation for if you're just doing a right heart cath with a biopsy, right, then the 93451 is the non-congenital right heart cath, 93505 and then the 75970, the 505 is the biopsy and then the 970 is the RSNI code that goes along always with the biopsy. So these two are always paired and then this is the non-congenital right heart cath. If you then add in, say that it's an annual or you're doing a left heart cath with coronary arteries, then you're going to add that in. So again, you're going to have the 93505 and the 970 for the biopsy component and then you're going to add the 93458 which is the non-congenital left heart cath which includes the coronary arteries with that. So then if the patient's disease is that of not an acquired but is failed from their congenital heart disease, then what you have to sort of look at is do they have anything what's termed as residual disease or residual issues which are related to their congenital heart disease. And we'll talk about what those residual issues might be some examples, but if there are no residual issues, they had a congenital heart defect, they had a transplant, they have nothing left over at all, nothing at all related to their underlying defect that they were born with, then you're going to go back to the schema that we just went through with the non-congenital codes for right heart cath biopsy as we laid out on the previous slide. And then if you're going to add in a left heart with coronary arteries, same thing, you're going to add in that left heart cath with the non-congenital left heart cath with the biopsy codes for that. So residual issues, what does that mean? The key here is that in somewhat like what both Mark and Sean have said, we can't lay out everything and there's going to be lots of things that we all encounter. We all encounter crazy, strange things in these patients. And so residual would be anything that you think is realistically and believably attributed to or as a consequence of their defect. So that could be something like pulmonary arteries that you previously had had to stent that maybe have some stent left over in it that you're having to address. Similarly, from a hypoplastic left heart, if they have some related, I'm sorry, some left over arch issues, they may have vena caval issues that were left over. You have a patient that during the course of their treatment and their palliative procedures, they were on ECMO and then as a part of that, even though they tried to repair when they came off ECMO, they lost the right side at IJ. So now you're having to come in from the left side because it's a non-standard sort of approach for that right heart cath and biopsy. Those would be some examples of things you would do that would say that you have residual disease from that. So that's what gets us into then using the congenital codes. So again, cardiomyopathies that are that of genetic origin, that does not have to be, and Sean sort of said this too, something that is in a neonate only. If it truly is something that is genetic, then it's something that they had at birth even though it may not manifest till later in life. More than again, fundamental failed congenital heart disease with any residual issues and it doesn't have to be a lot of things. It can just be any one thing there. And then you're going to switch then to the congenital cath codes. So again, your 505 and your 970 for the biopsy and then the congenital right heart code for congenital abnormal native. And then in this situation with the congenital codes, any additional angiography that you do, you need to code those things. So if you take pictures of the pulmonary arteries because you're evaluating those or the aortic arch or the SVC, then you need to put in those appropriate codes for that. If you're going to add in and do left heart cath and cores because it's their annual, then you're going to do the 505 and the 970 for the biopsy. Add in now the congenital right left for abnormal native. And then in that situation because you're doing the coronaries, in the congenital left heart cath, it does not include the coronary angiography. So you can add in this 93563 for coronary angiography. And then again, similarly, any other angiograms that you do during the course of the case, you should and need to code and build those things. This is another one that's a point of discussion and debate is fortunately the group did a good job in setting up these codes and the 93598 for thermal dilution, while it cannot be utilized for the non-congenital cath-based codes, it can be used with congenital codes. So all the codes that Sean just went through, if you do a thermal dilution with that as part of it, it is not bundled into the right heart cath. So in these kids that you're doing post-transplant biopsy, right heart cath, and you also do thermal dilution, you should put in the 93598 for the thermal dilution component of that. So again, anything that's residual, what's key here is that you provide wording and documentation that supports that. Something that tells and talks about why you're doing what you're doing, it will help to support that from your coders and billers standpoint, and it'll just help to make it so that it's less questionable. So there's no like template to use, but just these kinds of phrases or wordings in terms of things that you're doing to try to explain your reasoning and your thought process for it. And that's it. So hopefully that helps a little bit.

post-transplant biopsy codes

congenital vs non-congenital cath codes

cardiomyopathies

genetic issues

angiography and thermal dilution