Good evening, everybody. This is Sean Botley-Valla representing the Sky Congenital Coding Workgroup Committee webinar. It's our sixth webinar. We're very happy everyone's joined, and we hope you'll learn something today. I will just go right ahead and start sharing my slides. So as I mentioned, this is the sixth webinar in our congenital coding group. The point today, we thought, was to go through these list of ideas. So the first thing I'll do is I'll provide a piece of code that's been quite a while since we had that as a webinar topic. We'll discuss modifiers and MUEs, which is medically unnecessary edits, or I'm sorry, unlikely edits. Dr. Hiramop will then follow up with new congenital venography code review. Dr. Sutton will discuss the review of relevant imaging codes. Dr. Curzon will discuss how we recommend coding for certain complex and rare case codes. And Dr. Ringwald, the other member of our group, will be monitoring the QA in the chat. If you'll see it on the bottom of the Zoom, it's best to use the Q&A function, please. And we'll be able to monitor the questions that way, and the respondents will also be able to see the answers in real time. So to get to the congenital base codes, here's a list of the code. These are the new codes of one of the first sets that we created in this group, and these replace the old congenital base cath codes. To remind everybody, they basically are based on the connections in the patient's heart, and that's the heart of what I'm going to get to, no pun intended, next. But there's a right heart code, a new left heart code, and then a combined right and left codes. And they're broken down based on whether it's abnormal or normal connections. The left heart code does not make that distinction. So if you do a left heart cath only, then you can use that code. I just thought this is helpful to show the value that we've created with this, the old code values versus the new code values. You can see not a huge increase for the normal right heart cath, but that's kind of what we expected. But you can see pretty significant increases. This is a new code, the abnormal right heart cath, pretty sizable value. The left heart cath, and then the normal and abnormal connections, right and left heart caths are all pretty significantly increased. These were the old codes. If you remember the transeptal, those are now, that's a separately billable code. So that did have a higher value, but not so if you were to actually do a transeptal and code for that separately. And so again, the reason we wanted to talk about this was even among the group, our understanding and kind of the way that we've been describing this has evolved. And over time with some wonderful questions at prior webinars, actually from you, from our friends and colleagues, this is the ultimate way that we've, that we feel that this is like most sensible. And I don't want to get into any, you know, Von Pragen versus Robertson debate, please, please hope, hopefully no one's that's bothering them. But the Von Pragen approach, I think helps set the framework for, for this distinction between normal and abnormal connections. And by that, I mean, he, Dr. Von Pragen talked about alignments and connections. And essentially to steal my own thunder, both of those have to be normal. And so what he meant by alignments was, or they meant by alignments was that the blood flow from the SVC and IVC went into the right atrium and then the right ventricle and then the pulmonary arteries. And then, you know, on the left side of the artery, the pulmonary vein to the LA to the LV to the aorta, but in the heart itself, the connections, the endocardial cushions between the atrium and the ventricles, and then the conus and semilunar valves connected the ventricles and great arteries. Those are also considerations when you're deciding if it's normal or abnormal. So as an example, normal connections, as I said a second ago, both have to be normal. So if you think about it, really, there's very minimal diseases that we take care of that are going to meet the conditions from normal connections. And that's a simple ASD, a simple, I'm sorry, a secundum ASD, simple VSD, PDA co-arc, any congenital cardiomyopathies, any primary pulmonary hypertension. If it was a acquired condition, we would be using the non-congenital codes. And really everything else is going to fall under abnormal because it's either going to be an abnormal alignment or an abnormal connection. And if either of them is abnormal, it qualifies. So and then of course, also any non-native connections. So remember the reason we incorporated the term native was a tetralogy patient, for instance, right? So if you look at the YPA conduit, all those alignments are now corrected or double outlet right ventricle, but the connections are not native anymore. So obviously that's going to be an abnormal connection. The reason we wanted to talk about this is specifically related to valvar stenosis. There was varying guidance we've given in the past where we'd recommended using abnormal connections for certain valvar stenosis, like critical stenosis, but then normal for others. And it just didn't make sense from a CPT standpoint. So really if the valve's abnormal, the valve's abnormal, that's an abnormal connection, regardless of whether it's critical or not. And then all the others I think are pretty self-evident. The next issue is what code to use with transplant patients. And this is still, you know, really I think the best way to think about it is it's kind of on like an honor system, essentially, that the question I ask myself and the question we recommend is, is the issue that's being investigated at the cath directly related to the kid's prior congenital heart disease? And so that's really the meat of it. I guess very rarely if somebody were to transplant a patient that had a secundum ASD, then technically that would be a congenital issue because what we're talking about is, you know, the work of what you're doing in the cath lab, and we're talking about that heart that you're doing the work on. So the vast majority of transplanted hearts did not have congenital heart defects, right? And so that's why if you do use congenital, use a normal connection code. But some examples where you would like run through some examples. There's a patient with a cable and asthmatic stenosis related to the transplant that would be non-congenital. You know, the non-congenital cardiologist, the adult cardiologist, so to speak, they deal with that also. It's not a congenital issue. Okay. An example I had was I had a patient with heterotaxy bilateral SVCs. The surgeons read, they basically built a neo-anomalic vein, they took the left SVC, sewed it to the donor anomalic vein. And that was incredibly stenotic. The kid was symptomatic from it. I had to dilate, you know, I did a cath, but I had to dilate and stent that. That was related to his congenital heart disease. I will say those subsequent caths, now that that's been dealt with, and I take him back to the cath lab just to do the routine right heart cath and biopsy, I use the non-congenital right heart cath codes. I only use the congenital one for those caths where I was dealing with that residual congenital issue. And then the same idea with like a Fontan with LPA stenosis that was pre-existing, right? The kind of classic, now it's recurrent. Again, if you're dealing with that LPA and you're stenting it, or you have to cath them for whatever reason to diagnose that, that's when you would use the congenital codes. Hopefully that helps bring a little bit of clarity. So then real quickly, I'll go through just a couple of scenarios to highlight when to use certain codes. One other distinction between these new codes is we no longer care about the left heart cath or whether it's retrograde, anagrade, through an existing defect, all of that is no longer applicable. So if you had, and I should have put this on here, I apologize, if you had a two ventricle patient and you start by doing a right heart cath, venous access only, but then you cross an ASD, sample the LA and pulmonary veins, that's a right and left heart cath. The same idea in a Glenn patient, for instance, bidirectional Glenn, you get venous only access from the neck and the groin, but you cross the interatrial communication, sample the LA, the pulmonary vein sats, again, that's a right and left heart cath. And the take home is that you don't have to get arterial access to bill a left heart cath. You have to, you have to assess left heart structures. And then here's another just side example of a case we did recently, which I thought would be a lot of sort of transposition patient. You take them to the cath lab to assess coronaries, you get arterial access only. This is the perfect example of where you would do the left heart cath only, and then whatever angiogram codes you use. But then on the same patient, you get venous access only, cross aortic valve, the sample the aorta and pulmonary aortic angiogram, again, it's the same code. So the method of access is not the defining factor here. And if you did diagnostics and you can actually go for the right heart cath of it as well. The fenestrated Fontan, we brought this up because there were also some connections, some questions last time. So if you have a fenestrated Fontan, it's an abnormal connection, there's venous access only, you don't cross the fenestration, it's an abnormal right heart cath and left, I'm sorry, that's abnormal right heart cath. If you get venous and arterial, it's an abnormal right and left. If you get venous access only, but you cross the fenestration, again, repeating myself, it's an abnormal right and left with a hyperplast. Again, they're going to be abnormal connections. Preglen diagnostic cath, arterial and venous access, it's abnormal right and left heart cath, arterial access only. And you do this to assess the arch, do injections, that's going to be the left heart cath angiogram. And then you can do the catheter placement codes when you go into the innominate artery. And then the upper extremity angiogram code. And then if you cross the BTT shunt, you can take additional angiogram for PAs, which are listed here. The other thing to mention is for the vein, not for the artery, catheter placement has now been, some catheter placements have been bundled a little bit more expansively. So in the past, first order vein was like the innominate vein, was not considered part of the right heart cath, but now they've bundled the innominate vein and that's why I've bolded and italicized it. So we used to be able to bill for the innominate venogram and innominate first order catheter placement there. You can't do that on the right heart cath. You still can on the arteries. The only exception that they've made is the femoral carotid and iliacs they consider to be included in the cath. So like I said here, you can't really bill those anymore for as a typical, because they're considered typical locations as above. That's just with catheter placement. The angiography codes still can be reported. And then to jump a little bit, I also wanted to quickly run over two updates that we've made. You know, the other thing that we want as a committee is to ongoing review how the codes are being utilized. And there were some great questions that people brought up from the adult or the quote unquote adult world where they're dealing with coarctation of the aorta related atherosclerotic lesions. And so we want to keep our code sets to be congenital heart disease only. That's very important to us, I think to all of us. And so we clarified that there has to be a true native coarctation that the patient was born with to be able to use our codes. That was one. And then the other was some patients have complex like mid aortic syndrome or transverse arthroplasia. And so we changed it to allow it to be used multiple times if you're treating different zones. So this doesn't count as, you know, one long stent that you're putting two stents in. It has to be two distinct zones, but that's been updated to allow for that. And that was actually becoming a pretty sizable issue. We didn't realize how many. There's a fair number of adults out there that have coarctation from atherosclerotic lesions. And then last slide here, trying to be conscious of time. The other thing, and Dr. Ng will discuss what this means in terms of the assistant codes, but we went through the list of commonly utilized codes that we use and asked for assistance to be added. These four codes did not allow for assistant billing, but we've added them. Arterial embolization, and not to steal other people's thunder, but they'll talk about why it's for pulmonary flow restrictors and coronary fistula embolization, TPA administration, arterial and venous, oftentimes sick kids, coronaries, PEs, you want to have two attendings in the room. And then device retrieval. If you have a complex ASD device, it's migrated and you have to go in and retrieve it. That can also oftentimes be a challenging procedure that requires two attendings. So those have all been updated to allow the assistant code now. And with that, I'll stop sharing and I'll turn it over to Dr. Ng to discuss the assistant codes and MUEs. Sorry, muted? Okay. Can you guys see my slides? All right, let me just start. So I'm going to talk a little bit about modifiers and CPT codes for that. I'm going to focus a little bit on the assistant versus co-surgeon modifier. I know that some questions came up about that, and talk a little bit about MUEs. Just to make sure, everybody, I highly recommend that you buy this book. Every year they come up with a new one in January. It's about $140 on Amazon, and you can get it actually cheaper at the AMA website, but it's really useful. I use it all the time to look up codes. We all know that modifiers are really used to supplement information or just care descriptions so that you can provide extra details concerning a procedure, provide a physician, and with that you can actually optimize or improve your billing when you use it appropriately. So this is one that we're all pretty familiar with, right? The modifier 63, which is basically performing a procedure on a baby that is under 4 kilos. Obviously we know that these babies are smaller, more fragile, and the complexity can be higher, and so therefore make sure you put that weight in. I usually put that on the first page so the coders can see that this is a kid that needs to have a modifier 63 on. So that's one that everybody's familiar with. You all know that this can add 20% additional value when you add that modifier in those patients. Now, just so you know, how insurers recognize it may differ. So Medicare and also Medi-Cal does not recognize the 63 code, so we end up using the 22 code for that. Again, it may vary from state to state, but certainly on the federal side, Medicare and Medi-Cal does not recognize this. Luckily, we don't have a lot of patients that are elderly. Let's talk about co-surgeons versus the assistant. For the co-surgeon code, this is the modifier 62. Basically, it describes two surgeons. In this case, one could be an interventionist, obviously in different specialties that are performing a procedure, a specific different procedure on the same patient in the same procedure timeframe. And so therefore, those two surgeons can code their particular procedure and use the co-surgeon modifier. A good example is a heart transplant, and of course, the hybrid valve implant is something that we all have done and that is also applicable in that scenario. So how is this paid? Basically, when you have a co-surgeon modifier, you get paid 125% of what is allowed and each person gets half. So that's 62.5% per co-surgeon here. So that's actually pretty helpful. Rather than be the assistant, you're the co-surgeon. Of course, I recommend that you talk to your surgeon ahead of time so that it's all clear and up front before you guys proceed. Otherwise, it gets into some conflicts potentially. Again, I find that this to be useful in some of the hybrid procedures in the OR or the cath lab. We'll go over some of this later on. The assistant code is actually 80, 81, 82. I'm not going to talk about 81 because that's really more about minor rows, brief assists. But basically, if you are assisting the primary proceduralist, only certain codes are allowed for that. And I'll show you the list where this applies. You can refer to your Medicare physician fee schedule to look at which codes are. It should be in these slides later on. And I know that the slides are going to be posted on the website so you guys can get some of that information there. It could also vary from state to state. Medicare allows, can change depending on which state you are. Medicaid, I meant. For example, in California, for us, the billers, we use 80 for Medicaid, 82 for academic centers as far as Medicare is concerned. So again, it can vary. So you guys just check with your local regional what's allowed. That's what I just said. So of course, I'm not going to talk about 81 at this time. Let's talk about the 80 assistant code. Now basically, one physician can assist another physician in performing the procedure. If the assistant interventionist or surgeon assists the primary, is present for the entire time or a substantial portion of the time, then that person can report the procedure as an assist and they use this as a modifier. You don't have to write a note, but the primary physician needs to note that in their procedure note to say that they had an assistant. A test question for this, whether you qualify or not, is that did that surgeon serve as a primary surgeon for at least a portion of the shared procedure? If the answer is yes, if you did the primary part, then you actually should go into the co-surgeon 62 modifier and not the assist. So that's really a question you ask to say, do you qualify for the assist or the co-surgeon? Now there are some changes in 2025. And as Sean had mentioned, there are four codes that were proposed by us requesting allowance of the assist codes. And basically, these are the transcatheter procedure for thrombolytic therapy in the artery and the vein. And then of course, I'm sorry, embolization for the arteries and the vein and then retrieval of foreign bodies. So those are added on to allow the assistant as of 2025. Again, the rationale was that some of these procedures can be quite technical and complex and requires a team to do this. So therefore, the assistant person is needed. And of course, fortunately, CMS agreed and basically allowed these four codes to have an assist code with a status indicator of zero. Now I'm going to go a little bit into what that means. It's pretty complex and I'll talk about it later on. But at least we know that these four codes, now you can use an assist code. But it's really important to document the necessity. If you don't document it, it may not pass. The key thing is to allow an assistant person only when the case is challenging and necessary. So that has to be described well in your procedure note. This is what the status indicators mean. Now again, it's different for the assist code versus co-surgeon. I'm going to go through this briefly. Zero, you have three statuses. One is if it's zero, it will cover it or it may cover it if you have documentation of necessity. If it's status one, pretty much you won't allow it. Two will cover it and it's going to give you 16% on top of whatever is charged. This is the link that you can go into just to look this up and get more clarifications. The status indicators for the co-surgeons, actually what makes it more confusing, it's reverse. Zero basically saying you're not allowed. Whereas one, it may allow if you have medical necessity. So for the two, it's reverse. Why they do that, I don't know, but it adds to the confusion. Two basically will allow you to cover as a co-surgeon at 62.5%. Okay, so here are the lists that can be used. And I think this is important for us to keep track in mind. For transcatheter valves, you're actually allowed, a co-surgeon, as long as you prove medical necessity or in the case of an assist, you're also allowed. But there are two different status indicators. Transcatheter septostomy is allowed for the assist code. If you put in a transcatheter shunt, for example, an atrial stent, that would be allowed as an assist. Coarctation also allowed as long as you give medical necessity. Endovascular stent for coarctation. Angioplasty for coarctation as well. These are all proving necessity. But again, if it's a two, then it is allowed. Percutaneous angioplasty, a native recurrent coarctation. Pulmonary stenting is also allowed. You allow assist and keep going there. You can do normal and abnormal in that scenario. This is all pulmonary revascularization codes here. And then, of course, the Fontan fenestration there as well. Transcatheter closure of the PDA. Again, in specific cases that you have to prove medical necessity. Arterial collateralization. Mitral valvuloplasty. Again, a bunch of these are there. And again, I know that you're not going to remember this, but look on the link and see whether that's something that you should pay attention to. The three that is highlighted in yellow are the new ones. As Sean said, foreign body retrieval allows an assist if you show medical necessity. Thrombolysis. And then for the infusion of thrombolysis. Sorry, that was repeated in the different CPD codes. And then thrombectomy as well. Mechanical thrombectomy and all the different codes there. And then hybrid stage one is an important one that we do. And then transeptal puncture. Modify 82 basically says that if you're an academic, a teaching center, you have to say that you don't have a qualified resident or fellow that's available in order to use this code. There are some gray areas here, of course. The hybrid OR is one of the areas because not every interventional fellow is actually qualified. We all know that they're undergoing training. Hybrid valve implants as well. So oftentimes you need two attendings, even if you had an interventional fellow there. Again, there's a lot of variations from state and regional differences. And again, work with your coders on this. Medicare accepts 82 but won't accept 80 in the non-teaching hospitals. Again, that's just something that should be noted. Payment modifiers. What are the rates that you get for 80? 81, 82, you get an extra 60% as the assist. For co-surgeon, you get 62.5%. And then of course the MEU stands for medically unlikely edits. Basically it's a unit of service. How many times can you use that code for one service? So for example, embolization. If you embolize a vein, an artery, you're allowed two for each of the codes. Not more than that. If you do venography, you're allowed four. Two above the heart, two below the heart. Pulmonary angioplasty, the initial one, you can allow one, but you allow seven subsequent angioplasties in other parts of the pulmonary arterial tree. Stent codes, you're allowed four. One for the unilateral, one for bilateral, and then you have one additional PA stents. I think that's it. So thank you. I'm going to hand it back to you guys. Thanks a lot, Frank. We know this may be a little bit complex, but we're realizing it's very important. And so next we'll hear from Dr. Guru Hiramath. He'll talk about reviewing the new congenital venography codes that we developed and launched last year. Good evening, everybody. Can you see my slides? All good? Excellent. So we reviewed the venography codes a little bit last year. I think this is a refresher, but we thought it's important to go over them. As interventional cardiologists, we often see complex patients like this, and I'm talking to some of the coders who may be on the webinar this evening. Patients who have complex single ventricle anatomy, like this child with a four-month-old heterotaxy right atrial isomerism who comes in for a pregland cath. And as part of the cath, as you can see here in the anatomy, the patient has a right SVC and a left SVC that is separate that connects to the left-sided atrium and a left-sided IVC. So today we're going to talk about how to code for some of these conditions. In this patient, we did a right SVC angiogram, we did an IVC angiogram, and we did a LSVC angiogram. Prior to last year, we always had to code for right SVC, which was 75827. We did have a code for IVC, which was 75825, but we did not have a dedicated code for LSVC. The other previously available venography codes prior to 2024 were extremity unilateral venography, whether it's iliac, femoral, subclavian, etc., which we still have access to, and we had bilateral venography codes for extremities, and we had a hepatic venography code in addition to the 75827 and the 75825 for SVC and IVC. But thanks to the work that was done in 2022 and 2023, since last year, we now have access to new codes, which includes 93584, which was specifically designed for an additional contralateral SVC. And so in this patient that I just showed, we would code the first or the only SVC as 75827, but for the second SVC, the left-sided SVC, we can now use 93584, which is 1.2 RVOs. And for all the coders on the webinar here, those left-sided SVC can come in various anatomies. As shown in this series of pictures here, there is in the middle a left-sided SVC that connects to the coronary sinus. In another patient here, there is a left-sided SVC in addition to the right-sided SVC in a large bridging vein that connects to the coronary sinus. Regardless, whenever there is an additional SVC, we will now be able to use 93584. Some other pictures of left-sided SVC. In this patient, there is a hemiazygous continuation to the left-sided SVC to the left-sided atrium. And the catheter course is further advanced through the left-sided SVC into the right-sided SVC to do a RSVC angiogram and LSVC angiogram. And once again, we can code 93584 here for the left SVC angiogram. The other new codes that were added in 2024 were the azygous and hemiazygous angiography codes. Azygous and hemiazygous veins are a pair of veins that drain the intercostals in the paravertebral area up to the SVC. But a lot of children with congenital heart diseases, we know have azygous in the hemiazygous system as a continuation of interrupted IVC and play important roles, especially in single ventricle physiology. So we have to go through them sometimes. We have to sometimes do angiography to figure out their drainage and sometimes even intervene on them. And now we have a separate dedicated code for the azygous and hemiazygous veins, which is 93585. Here in the series of examples, you can see azygous vein on the first picture draining into the SVC as a continuation of the left-sided IVC. And in the picture on the right, we see hemiazygous continuation and drainage into the pulmonary arteries. But once again, we have codes specifically designed for this anatomy, which we can use. We also have developed a new code for coronary sinus angiography that is 93586 that provides 1.43 RVUs. Here's an example of an initial angiogram that was performed in a fontan lateral cable tunnel pathway and angiography revealed an incidental finding of coronary sinus shown here with the asterisk draining into the fontan pathway. And the catheter was then further advanced into the coronary sinus to do selective angiography to diagnose this coronary sinus connection. And now we can code for that coronary sinus using 93586. But once again, it's important to document that this was identified on the initial fontan angiogram and then further evaluation was performed with selective angiography inside the coronary sinus. That is a nice segue for veno-venous collaterals, which we often see in children with congenital heart disease. Here we have a picture of a nominate vein angiogram that is performed in a single ventricle fontan. And we notice V-V collateral draining from the left nominate vein to the pulmonary vein. We see that often when we do angiograms. The veno-venous collateral is then further selectively engaged to diagnose the appropriate drainage of this collateral. So in this case, we can initially code the nominate vein and the SVC angiogram separately. And in addition, we can code the V-V collateral angiogram using 93587. This provides 2.11 RVUs. The thing that is important to remember is that this code, as Dr. Ying mentioned, can be only used twice, but no more. So that is a MUE of 2. There is a separate code for veno-venous collaterals arising below the heart. The code that I just talked about previously was veno-venous collateral above the heart. But we often also find veno-venous collaterals below the heart as shown in some of this angiogram here where a catheter is selectively engaged into collateral that was identified on an IVC angiogram. And this collateral now drains from below the heart to the systemic vein to the pulmonary venous connection. So here we can use a 93588 code, which is again 2.13 RVUs. But once again, this code can only be used twice, also known as a MUE of 2 and no more. And lastly, what is the application? Once we find collaterals, we often go and embolize them as I did in this particular scenario. And as Dr. Ying mentioned, we now have a dedicated code for vascular embolization of a venous collateral, which is 37241. This code includes embolization, catheter placement, and interprocedural road mapping. But what is important for us to realize is that you can still code for 37241, the coil embolization of the collateral, and code for the diagnostic angiogram that was performed before the collateral embolization to diagnose the collateral. So we can build for the IVC angiogram, if that is the one that showed the collateral. We can build for the venous collateral selective angiogram that was used in diagnosis. And then we can build 37241, which does not include the diagnostic angiogram, but does include road mapping angiograms. I hope that makes sense. And that's it for me. Thank you. Thanks, Guru. Chris will, I think, actually talk a little bit about some of that stuff at the end, because it's another great thing to mention is these differences between diagnostic and road mapping angiograms. But first, we'll hear from Dr. Nicole Sutton on review of relevant imaging codes that we use in the cath lab. I'm sharing my screen. Thank you. We're going to talk about some of the imaging codes. So the outline, we'll talk about access, ice, portable C-arms, some 3Ds, balloon atrial septostomy, and intracardiac stenting. So for access, ultrasound guidance for access is 76937. This is using ultrasound. This can be listed separately in addition to code for primary procedure, but these are for non-congenital cath codes. The congenital codes already include these. Now, just so you know, if you're going to do this, you must document, you must save the images, and you must document the access. And that's why I have here some language that can be used for that. What size sheath you used, that you used it for puncture, and that they were stored in the PAC system. For ice, the intracardiac echo code is here, 93662. This can be used to report ice procedures during diagnostic or therapeutic interventions. It can only be reported once per patient encounter. You use it in conjunction with your primary procedure. So if you're doing a melody valve, an ASD closure, whatever you're doing, you can add this to that. Includes the imaging supervision and interpretation. And if ice is the only procedure performed, it actually, you use the unlisted code, 93799, if it's ice without any intervention or CAP. For documentation, it's very important that the images are saved, that the medical record should clearly state that the procedure was performed, what was seen, measurements taken. Some places report ICE as ECHO. We use our ECHO format for our ICE reports, and you need to have your interpretation of those findings. We've had people get in trouble for not saving the images or not being clear about the documentation. For portable C-arms, I'm sorry, I feel like I'm doing a little bit of a grab bag of things, so I feel like I'm jumping between topics, but for portable C-arms, now this is becoming more common as people are getting little C-arms because you can bring them maybe up to the ICU or to other places to do things. The CPT code is 77001. This is for fluoroscopic guidance for central venous access for diagnostic or interventional procedures. This includes imaging supervision and interpretation. You can use it for placement or removal procedures, any contrast that you use during that time, but you must save the images and make a report as you would for another CAP. The other code that could be used is 77002. This is for needle placement. This is specifically can be used for biopsies, aspiration, injections, or to mark a location for a surgical procedure. Once again, must be documented in an operative report. Requires permanent imaging and description of the imaging procedure. Can be reported in addition, so say this is an add-on to something else, you can code this in addition to another procedure, and it can be reported for each separate service. So, if you're doing different sites, like you have to do aspirations in different sites or injections in different sites, you can do that. Depending on the payer, you may be able to get multiple payments. We go to 3D spin imaging. So, there's two different codes, and this depends a little bit on your workstation capabilities. 3, 6, 3, 7, 6, and 7, 7. So, 7, 6, you report when the 3D post-processing is performed on the scanner in which you get the pictures and doesn't require an independent workstation. And 7, 7 is when you have to do it on a separate independent workstation. Both can be performed under the concurrent supervision of a doctor, meaning the doctor doesn't actually have to perform the post-processing. A technologist can do it under your supervision, but the physician must be actively involved in that process. And this is what that means. Design the anatomic region that is to be reconstructed. Determine the tissue types and the actual structures to be displayed on the 3D reconstruction, i.e., do you want organs, vessels, however you want it to look. Determination of the images or sine loops that are to be archived, and then monitoring and adjustment of the 3D work product. So, the physician could still even be scrubbed in or doing something else as long as they're supervising this process. Now, for 3D echo guidance, there's only one code for the actual 3D echo. This is in addition to the base code for the imaging. So, if you're doing a TEE, this would be an add-on to that. This is for the 3D imaging. You can use it for transesophageal or transthoracic. And then you add the prior codes, the 7-6 and the 7-7 for the 3D rendering. And that, once again, depends on your workstation capabilities. If it's a separate system, a separate workstation, you use the 7-7. So, this would be especially for people doing 3D, maybe transesophageal or transthoracic echoes as guidance. Once again, all the images need to be saved, and you need to have a report generated for your 3D images. Now, this is a little bit different, but BAS got added in. The code for BAS is 3-3-7-4-1. This is transcatheter atrial septostomy for congenital cardiac anomalies to create effective atrial flow. It includes all imaging guidance and using any method of making this atrial communication. So, rashkin balloon, cutting balloon, blade septostomy, does not matter. It's all the same. You can't use the modifier 63, even if it's performed on an infant less than 4 kilos. You can only bill for a right and left heart cath if you do more than the right atrium and left atrium pressures. If you only do RA and LA pressures, that is included in the BAS code. And angiography codes also could be added as long as it's more than the RA and LA. So, the RA and LA pressures and imaging are all included in the BAS code. And this could be for making any atrial communication. Now, the other one is intracardiac stenting. And this one, I think, comes up and I tried to put in all the specific examples that we could think of for where you can use this. So, this is 3-3-7-4-5, intracardiac shunt creation by stent placement to establish improved intracardiac blood flow. That could be the atrial septum. That includes a sinus venosus ASD stent, pontan fenestration stenting, RVOT, sono shunt, mustard stenting, warden baffles. Multiple stents in a single location are considered one code. So, if it takes two stents to do this, then you can only bill for one. Multiple locations are different. So, if you have an add-on code 3-3-7-4-6 for each additional intracardiac shunt creation by a stent. So, you can use the 3-3-7-4-5 if you do an atrial septal stent, and then maybe you do a sono stent, then that would be 3-3-7-4-6. So, you can do two stents at the same time. They include any and all balloon angioplasties performed in the target lesion, including the pre-dilation and the post-dilation, and any use of larger or smaller balloons to achieve your therapeutic results. So, this contains all things in putting in that stent. So, pre-dilation, post-dilation is included. Angioplasties in separate lesions can be reported separately, but this involves everything putting in that stent. If you take angios, you do balloon dilations before and after, that's all included. That was my last slide. Yes, somebody just mentioned in the chat, pulmonary vein stents are absolutely considered intracardiac as long as part of it's hanging into the atrium. If it's completely out in the periphery of a lung, like a lobar branch, unfortunately that would just be vein stent. But yes, pulmonary vein stents, absolutely, that's exactly why we had that add-on code added. If you do three pulmonary vein stents, that would be one initial and then two additionals. You know, one way to test that question is if the stent embolizes, would it fall into the heart? And if it does, it fits the intracardiac stent. Same reason the sinus venosus defect would be an intracardiac stent, as Dave Balzer just mentioned. Dave Balzer had asked that question. I mean, that's by definition in the heart. It's already in the heart, but yeah, it's an intracardiac stent also. And now we'll hear from Dr. Kursan to talk about some of the, what we thought would be the current rare and complex procedures, what codes to use. If we ever develop, and you know, we may never develop a code for some of these to be quite honest because the numbers are relatively limited, but if we ever did, these are the codes to use in the interim. Thanks. Thanks, Sean. Are you seeing these okay? Yep. All right. So I want to talk about a few different of kind of these more rare or complex type of interventions that we do run into and see. And I think we've talked about these a lot. We often run into questions or there are a lot of questions that get raised about it. So I thought we would cover some of these topics. So that of coronary artery fistula occlusion or embolization, placement of any pulmonary artery flow restrictors, and then stent angioplasty of either a PDA or a BTT shunt, something in either case there. We're talking about it in the scenario for providing pulmonary blood flow. So when you talk about coronary artery fistula occlusion, the code for that is the simple for arterial embolization. So this would be one that you would utilize for other artery embolizations as well. But this is the case you would use. And so this talks about here in the long verbiage of what it reports and what it includes. And note that it says here some of the examples it gives is for that for arterial conditions for not hemorrhage or tumors. So there's different codes for that, which is outside of our world. But the examples it gives is AVM, AV fistula aneurysm, pseudoaneurysm. But the important thing here is this example is not an all-inclusive. And so that's why we're going to advise you that this would be the appropriate code to utilize for arterial embolization for a coronary fistula. And the same code then is also going to apply if you were going to be doing pulmonary artery flow restrictors. I'm sorry, I skipped over one here. Let me go back to the coronary artery fistula. So if you're going to try and break that down and look at what kinds of how that would look from an overall coding perspective, is you're going to be able to build left heart cath, the congenital code for the left heart cath, as Sean pointed out to us earlier. If you did do a right heart cath in addition for some other reason, then you could do the combined right left heart cath with normal native connections. Assuming you did an aortic root injection or a supervalvar aortic angiogram, you could do the 93567. And then you could do selective coronary angiography that's performed to diagnose and define what your coronary fistula looks like, what the anatomy of that is. And this was mentioned briefly by Guru in some of the venous stuff, and the same topic applies, meaning that the injections you do here are for diagnostic purposes. Then you move on and you do the 37242 for the arterial embolization. That includes the embolization and further sighting and road mapping and things like that. But do not mix up in your mind and think you cannot do or build and code for the coronary angiograms that are diagnosing. And that's the key there is that it's a diagnostic angiogram. And you can and should word it in such a way that it was a diagnostic image to evaluate the coronary anatomy and the fistula's connection and then to describe that further. Similarly, you're going to use actually the same code, the 37242 for arterial embolization. Again, keeping in mind that this example listing that it gives is not an all-inclusive list. And what you're doing is you're effectively occluding or embolizing, putting something into the middle of the pulmonary arteries. So that's where using this code in this situation comes into play. So how that might look would be you're going to be into the right heart structures. So at the very least, you're going to be doing the right heart abnormal native connections. If you also, for some reason, in the context of the cath, we're doing left heart cath and getting the left heart structures, obviously, you could do the right and left heart as your base code. So either or there, not as either. I mean, not as in addition to. And then depending, the angiography is going to depend upon what you do, right? So we have newer codes in the recent years for the pulmonary artery angiography. So if you were to do, again, as a diagnostic imaging into selective into the right and the left pulmonary artery, and that is your imaging that you perform as diagnostic to then place the flow restrictors, then you could use the pulmonary artery selective for bilateral, assuming you're placing flow restrictors in bilateral pulmonary arteries. So that would be the 93573. If you do it as a non-selective in the main pulmonary artery, not in either branch specifically, then you can do the 68 for the non-selective. And then again, you would do, if any other images you did in the positioning of and things like that for sighting for the device placement, keep in mind that that is involved with the embolization, quote unquote embolization, or the occlusion. But do not short yourself, and make sure you do code for the diagnostic images you perform in the pulmonary arteries to help you with those. We'd recommend strongly that you do, I'm sorry, and on the 37242, that's per surgical field. So you can do that code twice, one for each field on the right lung and one on the right side of the chest and one on the left side of the chest. You know, this gets a little funny when you think of it as embolization. And so one of the things is keep in mind your documentation, and we've hit on this in a couple of other places too, is if you improve and are careful and precise in your documentation, the verbiage you choose, you can make your coders' lives a whole lot easier if you empower them basically without making it kind of ambiguous. So saying something in the narration of your text of something like a placement of a fenestrated occluder device, parentheses, or flow restrictor, use both occluder, because it's an embolization, and then however you want to word and verbalize flow restrictor in the proximal pulmonary artery, blah, blah, blah. But then in doing so, you make it a little bit easier to substantiate what you're doing in the use of this code for arterial embolization. Like Sean said, these are things that are rare. We don't do them a lot. The numbers that are needed for us to be able to push through for a code at this point in time, we just don't feel that it's worth the bang for that. So this is what we're advising at this point in time. The next one I want to talk about is either PDA stentine or BTT stentine, that for pulmonary blood flow, right? So these have a couple of different scenarios that this can occur in in terms of some of the additional codes you can use for that depending upon how you're approaching it, what you're doing. You can see in this situation that my catheter's coming in from the left arm because we did a left brachial arterial stick on this. But again, the approach isn't really so much what matters. It's what you do to get to it. So for PDA stent angioplasty, this one gets a little bit hard for sometimes for some people to think. If you access the artery and you're going up to the PDA and you then are accessing into the pulmonary arteries, you are accessing right heart structures. So in that situation, and if that's all you do is you're going in, you're assessing and accessing across the PDA to stent it with the intent for stenting it for pulmonary blood flow, you are performing a congenital right heart cath via abnormal native connections. If you do additional cath procedures or cath data that would substantiate for a left heart cath, you could obviously do that. But in this situation, you would do the congenital right heart with abnormal native connections because of the right heart structures that you're assessing and tackling. Then again, these next ones sort of depend upon what you're doing. If you do a descending thoracic aortogram, you position your catheter in the descending thoracic aorta nearby or adjacent to the PDA and you do an injection there, then you could code for this. If you had advanced your catheter around and did an ascending aortic angiogram, obviously you could do that. An injection into the duct, as you saw in the pictures that I showed in the stenting runs that I showed previously, at the duct and injecting into the duct and into the pulmonary arteries, you can code that as a non-selective similar to what you would be doing into the main pulmonary artery. You're not into either branch selectively, so you can do the non-selective pulmonary arterial angiogram. Then your pulmonary artery stent codes is what comes into place here. This is not an intracardiac nor is it a coarctation or an aortic stent. This is a pulmonary artery stent. We have these codes that are newer codes that we can use now for these. These are the 33902, 03, and 04. Those are all for pulmonary artery stents for abnormal connections, either initial unilateral, initial bilateral, and then if you do additional stents in the context of that same procedure. I'll show you some diagrams in another couple slides that sort of lay out some of those things and what that looks like with some advice on how you can look at that and how to think about the stenting of which of those codes to use. The BT shunt angioplasty is going to be very similarly. Again, think in your mind that you're accessing right heart structures via the BT shunt to get into the pulmonary arteries. That's how you can utilize and justify for right heart cath. Again, if you're doing left heart cath assessment, you could code that instead of a simple right heart cath. Again, supravalvular aortography, if that's what you do, versus if you just go up, you get your catheter positioned assuming that the BT shunt is off of the right inominate artery, then you would do the upper extremity unilateral code for that angiogram if that's what you did. But if you did a supravalve aortogram and you didn't then select it into the inominate artery, you could code for both of those things. And then again, you're going to be able to do the non-selective pulmonary artery angiogram as you would have on the PDA, assuming you engage to the BT shunt and you're injecting directly into that. And then again, similarly, you're going to apply the pulmonary artery stent codes, either the initial unilateral, the bilateral, or each additional, depending upon what you're doing there. So some examples of what that might look like, okay? So this is just some schematics. This is not all inclusive. These are just some ideas and some ways for you to sort of think about this. And some of you may have seen this on previous webinars when these codes first came out for the pulmonary artery stenting. So the diagram demonstrates subclavian artery with a BT shunt coming into the pulmonary arteries. And in this situation, this would be the 33902, which would be your first, your initial pulmonary arterial stent unilateral. So you've got one stent going toward one. And having it project into the pulmonary artery does not necessarily indicate what you're doing there. So this would be one stent there. If you then were addressing, say that in the same context that you're addressing the BT shunt narrowing, the LPA is narrowed and stenotic at its takeoff at this point, in such a way that you put a stent into the BT shunt distally, and then you put a second additional stent to address specifically a stenosis within that vessel, then that's going to give you your initial LPA stent, the unilateral, and then an additional stent because it's sort of contiguous with the initial stent you placed, but it's addressing a lesion. It's not just extending your stent further through the BT shunt or something like that. In example C here, in this case, you've got your initial BT shunt stent at the distal portion. It happens to extend or push toward the LPA, but you're not addressing a lesion within the LPA. But however, maybe the RPA had a stent. And this just happened to be where you opened this up to because of the lie of your wire or the direction of the catheter to get that initially opened, and you placed an additional stent into the RPA to address a secondary lesion, a different lesion. So again, it's not just continuous with your BT shunt stent. So in this case, you're going to do your bilateral stents because you've got one stent that kind of extends towards the left PA, and you've got a second separate and distinct stent that goes into an additional branch, a different branch that then was addressed. And then in this final example, again, you've got the shunt, the distal portion of the shunt getting stented, and you had both stenoses of both branch pulmonary arteries coming off of the end of the stent – I'm sorry, off the end of the shunt, and both needed to be addressed. So in this case, you're going to be doing it as the bilateral because you've addressed both, but you've got an additional one that's extending off of the first one. So you could do bilateral plus one each additional, like the each additional code, the 9904 for that. In this, what you're doing, and again, Sean talked about this some of the with the baseline codes, what we're coding for, what we're trying to do is code for the work that we do, and placing a couple of stents in tandem within the shunt versus putting a stent here and a stent separately to address a pulmonary artery stent. This requires more work than just this. A secondary stent to address a separate distinct lesion requires more work, and so you're having to reposition your catheter, reposition your wire, advance into a different lesion. So you're trying to justify and demonstrate what your work is that you did there. And that is it for me. Thanks, Chris. We've been getting some great questions in the chat. Jeremy, did any strike you as something you want to highlight to everybody? go through some, I can tell you a couple of the right-of-way picked up my attention as I responded to a little bit. I actually asked Monica, one question was kind of like, what defines a right and left heart cath? And that's been a question I've had everywhere. For instance, like Henry was alluding to this with the coarctation code. If you didn't go into the LV, can you call it a left heart cath? And the short answer is yes. The CPT codebook, the terminology was simply that a left heart chamber has to be accessed. And so, you know, this is my not kind of formal response is I think you just have to justify your answer, but your choice. If you go into the left heart and get pulmonary veins in an LA sat and a sample, that certainly justifies the left heart cath. If you're doing an ASD case, although I know you wouldn't bill for it and you just pop over and get a left upper pulmonary vein sat just because, you know, I wouldn't bill left heart cath personally for that. But there are no like technical definitions on a minimum criteria that, you know, that you have to get two pulmonary veins in an LA and an LV, for instance. So it was a good question. Can I just throw something in regarding the assist codes? I know that there are actually several important congenital heart interventional codes where an assist can be used. And I know oftentimes for these very complex cases, we have two faculty there and you would hate to not bill for something that is legitimately useful. And again, like I said, you know, if you do this right and indicate medical necessity, you get another 16% for the person who spent time in the cath lab with you. I know that some of the private insurance will pay as much as 20%. So again, it's not some change for a lot of these procedures. We do spend a lot of time helping each other. And so I think that don't forget to use some of the assist codes and know what codes can be used. Frank, may I ask you a question about assist codes? Some of the common things that we have double scrub in our place are PDA stents, pulmonary valves and tricuspid valves and VSD closures. Would those be co-surgeon thing or an assist for a modifier? That's a great question. Again, I think the test question is that if the assist person is actually doing the primary part in this procedure, then you can use it as you can. It justifies the co-surgeon. But again, if you're talking about one specific procedure, you really can't have two people doing the same procedure. So to me, it's really two different procedures within one service where the co-surgeon can be used. So to me, I think that if you're doing, let's say, for example, a PDA stent code, you're helping somebody from below and above. You're not necessarily there for the entire time, right? One person is doing the diagnostic part and then the angiography, you come in and scrub in to help. So to me, I would use that as an assist, not a code. So Frank, we had a question from Rachel Taylor about an assist code. Does it require a separate report? I don't think so, but you need to document that both people are present, right? Yeah, I think the primary person has to document that, but I think the key thing is to document why this second person is needed for the procedure. As long as that's there, the insurer will at least consider paying out that extra 16% or 20% depending on the payer. There's a couple of questions coming through because they said the co-surgeon, I think the quintessential example of the co-surgeon is a TAVR, where the adult CT surgeon is there. They do one aspect of the procedure or transplant surgery. For instance, I've gotten into liver transplants. There'll be one liver transplant surgeon doing the recipient, like hepatectomy, and one transplant surgeon doing the donor hepatectomy and things. That's a co-surgeon. They're doing very, very different things. Basically, I think to be simple, two interventionalists scrubbed on the same procedure, that's assistance. And then there's a question of like a PDA closure during an EP case. That's not relevant because you're not going to be coding the same procedure. You're going to code a PDA closure and the EP team is going to be coding their EP procedure. So that's different. This would be like there's a TAVR code, like we said, like we were talking about. Both people put that same CPT code in with those two different modifiers. Or liver transplant, there's a liver transplant code and the surgeons put in the different modifiers for the one taking the organ out and the other putting it in. Co-surgeons is going to be rare for us, I think. Sean, you mentioned, sorry, you mentioned, Sean, the example of an EP procedure with another interventional procedure. There actually is another modifier. I didn't go over that because there's actually several. I just want to focus on assistant versus code today. But there is another modifier where two separate specialists do two separate procedures within one setting that you can use. Yeah, OK. That's good to know. Yeah. For us, the common example is a hybrid stage one where the surgeon places the PA band and we do the tuckle stand. I think that is one scenario where we commonly can use the co-surgeon code. There's a question about Fontan fenestration. Test occlusions, if you don't leave anything behind, unfortunately, can't really bill for that. Some people will bill for physiologic fluid like challenge, pulmonary vasodilator challenge. In some places, they've, you know, if you can make an argument that it's some kind of, that may be it. But otherwise, it's an intracardiac, if you create a Fontan fenestration, that's an intracardiac extent code. If you close a fenestration, it's an ASD code. And those have been, those are in the uh, the codebook itself. So, would you say, Sean, that either creating a fenestration or stenting a Fontan by itself are both intracardiac extent code, right? Yeah, yeah, that's a great point. Yeah, yeah. As Frank alluded to, right, just like the litmus, easy litmus test for that is if the stent demolizes, does it have potential to go into the heart? Yeah, yeah. But in the same Fontan, if you stented the LPA, that's a PA stent code, unilateral abnormal connection, right? Right, right, yeah. Here's a question from Greg Fleming, and I think Jess Randall had also asked this earlier, what about when you're working with the adult cardiologists or ACHD interventionalists, what code are you going to use? You know, if you're doing the same procedure, right, it's two different specialties, but if you're not doing two distinct procedures, you cannot use co-surgeon, you have to still use assistant surgeon is what I'm thinking, what do you guys think? Yeah, I mean, typically the co-surgeon, like in the TAVR model, they document separate notes. And I know, I don't know if it's, I don't know if they need to, but I know our liver transplant surgeons document two separate notes, and they will refer to it. They'll say my co-surgeon did this, refer to their note, I did this in that note. And then they both bill, yes, using the co-surgeon code. And that's where Frank also alluded to, you want to talk beforehand about who's going to be the kind of first primary one to submit it, right, Frank, like you were saying, because there'll be different payouts. Yeah, and I think the key thing is you don't want to miscommunicate and assume. So I always talk to my surgeon if we're doing this, I say, okay, am I your co-surgeon? And make an agreement, otherwise you fight each other and problems arise. So we had a, we have a question about when they look at the rights of clavian artery looking for collaterals, do you use a MAPCA code or do you use a second order arterial code? That's just the rights of clavian artery code. Okay. Dennis, we may talk to you about some of the automated things you're doing about billing, because that's very much where I'd like for us to move personally. We can maybe talk offline, and if you have something to share with a larger group, we may ask you to share that. Dennis had put something in the chat about using Epic to bill and then being verified by coders, and it seems like the process may be helpful. I would encourage the attendants to ask questions and send it to us, because we use these questions to try to decide what's the next webinar, and what's interesting and what's important to the participants. And before I forget, I think we should thank Monica Wright for really helping us coordinate this. She's the Sky Liaison for the coding group, and we use her as a tremendous resource. So thank you, Monica, for helping us. Well, all right, everybody, as Frank just said, please feel free to email all of us. I mean, I know we're all, most of us, all the interventionists, we're all friends, but everybody else, please email us. We want feedback. We want to continually improve. If you notice any issues, let us know. But otherwise, really appreciate you joining. And just for people that may have missed it in the chat, all the registrants will get copies of these slide decks, and you'll also be able to get MOC credit, which is nice. Otherwise, thanks so much, everybody. Have a good night, good evening. Yeah, just, oh, sorry. Good night, everybody. Night. Bye, everybody.

congenital cardiac coding

medical billing

catheterization codes

coarctation of the aorta

PDA and BT shunt

venography codes

documentation

diagnostic interventions

therapeutic interventions

MOC credit