CPC 2025 Test Chapter 8

Cardiovascular System

Introduction

  • This chapter reviews the cardiovascular system.
  • Relevant codes are in CPT (surgery, radiology, and medicine), ICD-10-CM (Chapter 9), and HCPCS Level II code books.
  • Objectives:
    • Explain common pathologies.
    • Highlight relevant procedures and CPT codes.
    • Introduce ICD-10-CM and HCPCS Level II codes and guidelines.
    • Provide an overview of anatomical concepts.
    • Define key terms, eponyms, and acronyms.

Anatomy and Medical Terminology

  • The cardiovascular system consists of the heart, arteries, and veins.
The Heart
  • The heart is a fist-sized, cone-shaped muscle (myocardium) that beats about 80 times per minute.
  • It is divided into right and left sides by the septum.
  • The pericardium is a two-layered protective membrane surrounding the heart and the roots of the great vessels (aorta, pulmonary trunk, superior and inferior vena cava).
  • Four chambers exist:
    • Atria (upper chambers) receive blood.
    • Ventricles (lower chambers) pump blood.
    • The left ventricle is the most muscular chamber, forcing oxygen-rich blood into the body.
  • Inlet and outlet valves ensure one-way blood flow.
    • Atrioventricular valves: tricuspid (right) and mitral (left) are inlet valves from the atria to the ventricles.
    • Semilunar valves: pulmonary (right) and aortic (left) are outlet valves.
  • Inlet valves are supported by chordae tendineae (heart strings) that link the papillary muscles to the tricuspid valve (right ventricle) and mitral valve (left ventricle).
  • Diastole: When the atria contract, the valves open and blood flows into the ventricles.
  • Systole: When the ventricles contract using the papillary muscles, the valves close to prevent backflow into the atria and prolapse, forcing blood out of the ventricles.
Oxygenation Process
  • Oxygen-deficient blood enters the right atrium via the vena cava.
  • The tricuspid valve opens and blood flows into the right ventricle.
  • Blood is pumped from the right ventricle through the pulmonary valve into the pulmonary artery to the lungs.
  • Oxygen-rich blood returns to the left atrium through the pulmonary veins.
  • The mitral valve opens and blood flows into the left ventricle.
  • The left ventricle forces blood through the aortic valve into the aorta and out to the body.
Conduction System
  • The electrical conduction system controls the heart, containing pacemaker cells, nodes, the bundle of His (AV bundle), and Purkinje fibers.
  • Pacemaker cells generate electrical impulses that cause muscle fibers to contract, making the heart beat.
  • The sinoatrial (SA) node (natural pacemaker) is in the right atrium near the superior vena cava.
  • The atrioventricular (AV) node is lower in the septal wall of the right atrium, slowing impulses between the atria and ventricles to allow atrial filling.
  • Impulses travel to the bundle of His, which branch off to the right and left.
  • The impulse arrives at the Purkinje fibers, which lie across the surface of the ventricles and signal the myocardium to contract.
Coronary Arteries
  • The heart needs a constant supply of oxygen and nutrients.
  • Coronary arteries are blood vessels that carry oxygen-rich blood to the myocardium.
  • The left and right coronary arteries emerge near the top of the heart at the beginning of the aorta.
  • The left main coronary artery branches into the left anterior descending and left circumflex coronary arteries.
  • Arteries branch into smaller vessels called capillaries.
  • In the capillaries, red blood cells (RBCs) provide oxygen and nutrients to the cardiac muscle tissue.
  • RBCs bond with carbon dioxide and waste, taking them away from the heart for disposal through the lungs, kidneys, and liver.
Blood Vessels
  • Arteries carry blood away from the heart.
  • Capillaries connect arteries to veins, which carry blood back to the heart.
  • Artery composition:
    • Outer layer: tough outer tissue.
    • Middle layer: muscular (strong and elastic).
    • Inner layer: epithelial cells (smooth for blood flow, withstands pumping pressure).
  • Veins are similar to arteries, but not as strong due to lower pressure.
    • Outer layer: tissue.
    • Middle layer: muscle.
    • Inner layer: smooth epithelial cells.
    • Veins have thinner layers with less elastic tissue and smooth muscle but more fibrous connective tissue.
  • Capillaries are single epithelial cells that are thin and fragile.
    • Blood cells pass through capillaries in single file.
    • Oxygen and carbon dioxide exchange occurs through the thin capillary wall.
Circulation
  • Three methods of circulation:
    • Systemic circulation: nourishes tissues throughout the body, except the heart and lungs.
    • Pulmonary circulation: movement of blood from the heart to the lungs and back, exchanging oxygen and carbon dioxide.
    • Coronary circulation: movement of blood via coronary arteries and veins to and from heart tissue.
Key Roots, Suffixes, and Prefixes
  • -lum: membrane
  • -megaly: enlarged
  • -ole: small
  • -oma: tumor
  • -sclerosis: hardening, hardness
  • -stenosis: narrowing; stricture
  • -stomy: artificial opening
  • -tome: cutting instrument
  • ather/o: yellowish, fatty plaque
  • angi/o; vas/o; vascul/o: vessel
  • arter/o; arteri/o: artery
  • arteriol/o: arteriole
  • atri/o: atrium
  • cardi/o: heart
  • ech/o; son/o: sound
  • electr/o: electrical
  • my/o: muscle
  • ox/i: oxygen
  • phleb/o; ven/o: vein
  • pulmon/o: lung
  • scler/o: hard
  • sept/o: septum
  • sin/o: sinus
  • steth/o; thorac/o: chest
  • venul/o: venule
  • brady-: slow
  • de-: down; from
  • epi-: upon; above
  • peri-: around
  • poly-: many
  • tachy-: fast
  • -ary: pertaining to
  • -edema: swelling
  • -graph: instrument used to record
  • -graphy: process of recording
  • -gram: recording, writing

ICD-10-CM Coding

  • Most diagnostic codes for the cardiovascular system are in ICD-10-CM Chapter 9: Diseases of the Circulatory System (I00-I99).
Arrhythmias/Conduction Disorders
  • Arrhythmia (dysrhythmia) is an abnormal heart rate or rhythm.
  • Common types: premature atrial contractions (PACs), premature ventricular contractions (PVCs), atrial fibrillation (AF), atrial flutter, paroxysmal supraventricular tachycardia (PSVT), ventricular tachycardia (V-tach), ventricular fibrillation (V-fib), and bradycardia.
  • Some arrhythmias arise from conduction disorders: abnormal electrical impulses in the heart.
  • Common conduction disorders: atrioventricular block, right and left bundle branch block (BBB), and Long Q-T Syndrome.
  • Most ICD-10-CM codes are in category I49 and subcategory O03.81 (related to pregnancy).
  • Separate codes exist for psychogenic arrhythmia (F45.8) and vagal arrhythmia (R55).
Hypertension
  • Hypertension (HTN), or high blood pressure, is classified as primary (essential) or secondary.
  • 90-95% of cases are primary hypertension, with no medical cause found.
  • 5-10% of cases are secondary hypertension, caused by other conditions affecting the kidneys, arteries, heart, or endocrine system.
  • ICD-10-CM coding guideline I.C.9.a gives direction on code assignment.
  • Hypertension is assigned to categories I10-I16.
Hypertension with Heart Disease
  • Hypertension with heart disease presumes a causal relationship between the heart disease and hypertension as the conditions are linked by the term "with" in the Alphabetic Index.
  • Hypertension and heart disease are coded as related even when documentation does not specifically link the conditions.
  • Report an additional code from category I50 to identify the type of heart failure, if present (multiple I50 codes may be assigned).
  • If the physician's documentation specifies a different cause, the conditions are reported separately.
Hypertensive Chronic Kidney Disease
  • Hypertension and chronic kidney disease (CKD) have a presumed causal relationship.
  • When conditions classifiable to N18 (Chronic kidney disease) are present, assign codes from category I12 (Hypertensive chronic kidney disease).
  • Use an additional code to identify the stage of CKD from category N18.
Hypertensive Heart and Chronic Kidney Disease
  • When a patient has both hypertensive heart disease and CKD, assign a code from category I13 (Hypertensive heart and chronic kidney disease).
  • ICD-10-CM guidelines specify an assumed relationship between the conditions.
  • Assign an additional code (or codes) from category I50 (Heart failure) to indicate the type of heart failure.
  • An additional code from category N18 is necessary to identify the stage of kidney disease.
Hypertensive Cerebrovascular Disease
  • When a patient has hypertensive cerebrovascular disease (I60-I69), code that condition first, followed by the appropriate hypertension code.
Hypertensive Retinopathy
  • Two codes are necessary: first, H35.0 (Background retinopathy and retinal vascular changes), followed by the appropriate code from categories I10-I15 to show the type of hypertension.
Secondary Hypertension
  • Two codes are required: one to show the underlying etiology and another from category I15 to identify the type of hypertension.
  • Sequencing order is determined by the reason for the admission or encounter.
Transient Hypertension and Elevated Blood Pressure
  • Assign R03.0 (Elevated blood pressure reading without diagnosis of hypertension) unless the patient has an established diagnosis of hypertension.
  • For transient hypertension complicating pregnancy, assign a code from category O14.
  • Gestational hypertension without significant proteinuria is reported with a code from category O13.
Hypertension, Controlled or Uncontrolled
  • Controlled hypertension refers to an existing state of hypertension under control by therapy.
  • Uncontrolled hypertension may refer to untreated hypertension or hypertension not responding to therapy.
  • Assign the appropriate code from categories I10-I15.
Hypertensive Crisis
  • Assign a code from category I16 (Hypertensive crisis) for documented hypertensive urgency, hypertensive emergency, or unspecified hypertensive crisis.
  • Code also any identified hypertensive disease (I10-I15).
  • Sequencing is based on the reason for the encounter.
Arteriosclerosis
  • Arteriosclerosis is hardening of the arteries.
  • Arteriosclerosis of the coronary arteries is assigned a code from category I25 (Chronic ischemic heart disease).
  • Code selection indicates whether the atherosclerosis is of a native artery, bypassed artery, or transplanted heart.
  • Angina pectoris is characterized by chest pain and is common in patients with coronary artery arteriosclerosis.
  • A causal relationship is assumed between coronary artery arteriosclerosis and angina pectoris unless it is specifically stated the angina is due to another cause.
  • Combination codes are used to report coronary artery arteriosclerosis with angina pectoris (I25.11, I25.7).
  • When combination codes are reported, angina pectoris is not reported with an additional code as it is included in the combination code.
Endocarditis
  • Endocarditis is inflammation or infection of the inner lining of the heart (endocardium).
  • Left untreated, it can damage or destroy the heart valves.
  • Bacterial infection is the most common source, but the cause may be fungi or unidentified.
  • Most codes for endocarditis are found in the categories I33-I39.
  • Acute rheumatic endocarditis is coded as I01.1, and chronic rheumatic endocarditis is I09.1.
  • Sometimes multiple codes are necessary to report acute endocarditis when the infectious organism is known or when the underlying disease is known.
  • The order will depend on the type of endocarditis (e.g., acute streptococcal endocarditis is coded I33.0, B95…).
Pericarditis
  • Pericarditis is inflammation of the sac surrounding the heart (pericardium), caused by infection.
  • Most codes for pericarditis are found in categories I30-I32.
  • Multiple codes may be necessary to describe the patient's condition if the underlying disease is documented.
  • Observe ICD-10-CM guidelines for sequencing.
Heart Failure
  • Heart failure (congestive heart failure) occurs when the heart cannot pump enough blood to supply the body's other organs.
  • Multiple codes may be necessary to describe the condition, or combination codes may be used.
  • Hypertensive heart failure requires at least two codes.
  • Acute systolic and diastolic heart failure are reported with combination code I50.41.
Peripheral Arterial Disease (PAD)
  • PAD affects the arteries outside the heart and brain.
  • It is the most common type of peripheral vascular disease (PVD).
  • If the only diagnosis given is PAD or PVD, report unspecified code I73.9.
  • If the PVD is due to diabetes, report E08-E13 with .51-.52, depending on the presence of gangrene.
Valve Disorders
  • The most prominent heart valve disorders are stenosis, regurgitation, and prolapse.
    • Valve stenosis occurs when one or more of the heart valve openings narrows and restricts blood flow through the heart.
    • Valve regurgitation occurs when the valve does not close properly.
    • Valve prolapse occurs when valve leaflets prolapse into the heart chamber.
  • Code selection is driven by which valve(s) is affected and whether the condition is congenital or acquired.
  • For congenital heart valve stenosis, look to categories Q22 and Q23.
  • For non-congenital disorders, determine if the condition is rheumatic, acute, or involves multiple valves.
Cerebrovascular Accident
  • A cerebrovascular accident (CVA) commonly is referred to as a stroke or cerebral infarction.
  • This condition is a result of the lack of blood flow to the brain.
  • Common signs are weakness or paralysis (usually on one side), trouble speaking, change in vision, confusion, severe headache, and problems walking.
  • When the provider documents a stroke or CVA with no additional information, the default code is I63.9 (Cerebral infarction, unspecified).
  • Look for Accident/cerebrovascular in the ICD-10-CM Alphabetic Index.
  • There are sequelae (late effects) that can develop because of a CVA.
  • Category I69 is used to indicate conditions classifiable to categories I60-I67 as the causes of sequela.
  • The sequela includes neurological deficits that persist after the initial onset of the CVA.
  • Neurologic deficits caused by cerebrovascular disease may be present from the onset or may arise at any time after the onset of the condition.
  • Sequela codes that specify hemiplegia, hemiparesis, and monoplegia identify whether the dominant or non-dominant side is affected.
  • If not documented, the default is:
    • For ambidextrous patients - dominant
    • If the left side is affected - non-dominant
    • If the right side is affected - dominant
  • Codes for I60-I67 can be reported with sequela codes from category I69 when a patient has a current cerebrovascular disease and residual deficits from an old cerebrovascular disease coexist.
  • Z86.73 (Personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits) is reported for patients with a history of CVA with no neurological deficits present.
  • A TIA is often referred to as a mini-stroke. It has the same signs as a CVA but is not long-lasting and does not result in permanent damage.
  • Pay attention to the instructional note Use additional code, found throughout category I69, indicating to report the condition, syndrome, or sequelae as a secondary code.
Myocardial Infarction (MI)
  • An MI, or heart attack, is a sudden decrease in the coronary artery blood flow that results in death of the heart muscle.
  • When an MI is suspected, the provider often orders lab tests to determine the levels of creatinine phosphokinase (CPK) and troponin in the patient's blood.
  • Elevated levels of CPK and troponin may indicate damage to the heart muscle.
  • If there is a diagnosis of elevated CPK or elevated troponin, the elevated lab result is coded from Abnormal findings on examination of blood, without diagnosis (R70-R79) in the ICD-10-CM code book.
  • There are five classifications of MIs:
    • Type 1: Spontaneous myocardial infarction related to ischemia due to a primary coronary event such as plaque erosion and/ or rupture fissuring, or dissection. This is the prototypic heart attack. An ST elevation myocardial infarction (STEMI) and Non-ST elevated myocardial infarction (NSTEMI) share the same pathophysiology and are both considered Type 1 Mls.
      • Type 1 MIs are assigned to codes I21.0-I21.4. Subcategories I20.0-I21.3 identify a STEMI. Code I21.4 is used for NSTEMI, nontransmural MI, or acute subendocardial MI.
    • Type 2: Myocardial infarction secondary to ischemia due to either decreased supply or increased demand (for example, coronary artery spasm, coronary embolism, anemia, arrhythmias, hypertension, or hypotension).
      • Type 2 MIs are assigned to I21.A1 with a code for the underlying cause, if known and applicable.
    • Type 3: Sudden unexpected cardiac death, including cardiac arrest, often with symptoms suggestive of ischemia, accompanied by presumably new ST elevation, or new left bundle branch block, or evidence of fresh thrombus in a coronary artery by angiography and/or at autopsy, but death occurring before blood samples could be obtained, or at a time before the appearance of cardiac markers in the blood.
    • Type 4a-4c: Myocardial infarction associated with revascularization procedures.
    • Type 5: Myocardial infarction associated with coronary artery bypass graft surgery (CABG).
  • Acute MIs type 3-5 are assigned to code I21.A9.
  • A subsequent episode of care must be provided within four weeks of the initial episode of care. After four weeks, the MI is considered old.
  • If the patient has a new MI within the four-week period of the initial MI, the second MI is considered to be a subsequent MI and coded from category I22.
  • Refer to the Excludes2 note for category code I21.
  • There is an instructional note under categories I21 and I22 in the Tabular List to use an additional code, if documented, to identify use or exposure or dependence to tobacco, or status post administration of tPA (rtPA) within the past 24 hours prior to the current admission.
Intraoperative and Postprocedural Complications
  • Codes from category code I97 (Intraoperative and postprocedural complications and disorders of circulatory system, not elsewhere classified (NEC)) are reported when there is a complication(s) of the circulatory system during or after a surgery-specific procedure.
  • These codes identify a complication that is diagnosis-specific (for example, I97.81 Intraoperative cerebrovascular infarction).
  • The 4th and 5th characters in this code category (except for codes that end with .8, .88, or .89) indicate the type of complication.
  • A 6th character indicates if the complication was due to a cardiac surgery/procedure or other type of surgery/procedure.
  • Documentation should indicate the condition (for example, hematoma) and the procedure (for example, cardiac catheterization) for proper code assignment.
Anticoagulant Therapy
  • Anticoagulant therapy is when a certain type of medication (for example, Coumadin) is used to prevent clot formations within a blood vessel.
  • This type of therapy is used for different types of vascular disorders such as, atrial fibrillation, pulmonary embolism, or venous thrombosis.
  • When the medical record documents a vascular disorder as a final diagnosis and documents that the patient is currently taking or has a long-term use of an anticoagulant medication, report code Z79.01 as an additional diagnosis.
  • This Z code is found in the ICD-10-CM Alphabetic Index by looking for Long-term (current) (prophylactic) drug therapy (use of)/ anticoagulants.

CPT Coding

  • Codes throughout the CPT code book may report procedures and diagnostic tests of the heart.
  • A coronary artery bypass graft (CABG) is coded from the 30000 section of CPT.
  • ECGs are coded from the 90000 section; and the radiologic portion of an interventional procedure is coded from the 70000 section.
Surgery (33016-33999)
Heart and Pericardium
  • A pericardiocentesis (33016) involves drawing off collected fluid (via a specialized needle) built up inside the double-layered pericardial sac.
  • Too much fluid can impede the contraction and effectiveness of the heart and can lead to a serious condition called cardiac tamponade.
  • A pericardial drainage (33017-33019) refers to percutaneously inserting an indwelling catheter for a longer term when temporary treatment is needed.
  • Refer to the parenthetical instructions of which radiology codes are not reported with this code range.
  • A pericardiotomy (33020) refers to an incision made for a clot/foreign body removal.
  • A pericardiectomy (33030, 33031) describes the removal of the fibrous sac (pericardium) surrounding the heart.
Pacemaker or Implantable Defibrillator (33202-33275)
  • A pacemaker or implantable defibrillator system consists of a pulse generator (battery and electronics) and one or more electrodes (leads).
  • The first word generally defines the procedure (e.g., 33202 is an insertion code, 33218 is a repair code).
  • A pacemaker uses low-energy electronic pulses to overcome conduction disorders of the heart.
  • An implantable defibrillator delivers electrical shocks and sometimes paces the heart, if needed.
  • CPT separates some codes by the type of system, such as 33222 (Relocation of skin pocket for pacemaker) and 33223 (Relocation of skin pocket for implantable defibrillator).
  • For pacemakers, determine if it is a temporary or permanent pacemaker.
  • Temporary pacemaker placement codes are 33210-33211.
  • Also determine if the system is single or dual chamber.
  • CPT codes 33206 and 33207 are for single-chamber pacemaker system insertion or placements.
  • CPT code 33208 is for a dual-chamber pacemaker system placement.
  • These codes are for entire systems. If only the generator is inserted, look to 33212, 33213, and 33221.
  • Electrodes can be placed transvenously or epicardially.
  • Epicardial electrode placement is further differentiated by approach-open or endoscopic.
  • Multiple codes may be needed to build the placement of the system when epicardial placement of electrodes occurs.
  • A dual-chamber pacemaker system inserted with epicardial placement of electrodes is coded 33202, 33213-51.
  • More than one code is usually required to describe the full procedure.
  • If a new system is placed after removal of an old system, code the removal of the parts and the insertion of the new system.
  • The removal of a dual system with replacement is reported with 33235, 33208-51, 33233-51.
  • There are two general types of implantable defibrillators: transvenous or subcutaneous.
    • Transvenous implantable pacing cardioverter-defibrillator (ICD) uses a combination of antitachycardia pacing, low-energy cardioversion, or defibrillating shocks to treat ventricular tachycardia or ventricular fibrillation.
    • The subcutaneous implantable defibrillator (S-ICD) uses a single subcutaneous electrode to treat ventricular tachyarrhythmias.
  • Review the CPT code book for the codes for implantable defibrillator insertion (33240, 33230, and 33231), removal of only the implantable defibrillator pulse generator (33241), and removal with replacement of the pulse generator (33262-33264).
  • Do not report 33262-33264 in conjunction with 33241.
  • Services for subcutaneous implantable defibrillators; the insertion or replacement of the system is reported with 33270. The removal of a lead is reported with 33272. Removal and replacement of the complete system requires codes 33272, 33241, and 33270.
Cardiac Valve Procedures (33361-33478)
  • Cardiac valve procedure codes are assigned by aortic, mitral, tricuspid, or pulmonary (valves).
  • Valvuloplasty (repair) works on the whole valve accomplished by sutures, patches, or rings, including the leaflets of the valve and the ring or the annulus.
  • Annuloplasty involves work solely on the ring (annulus).
  • Replacement of the valve can be performed using either a mechanical or a biologic prosthesis.
  • If more than one valve is operated on, report separate codes for each procedure.
  • Codes 33361-33369 report transcatheter aortic valve replacement with a prosthetic valve through various approaches (percutaneous femoral artery, open femoral artery, open axillary artery, etc.), and there are separate codes for various transcatheter approaches with the use of cardiopulmonary bypass.
  • These procedures require two surgeons, report with modifier 62.
  • Review the guidelines in the CPT code book for 33361-33369.
  • Diagnostic coronary angiograms may be reported separately when certain criteria are met. The requirements are included in the CPT coding guidelines.
  • Most open aortic valve surgery is performed while the patient is on cardiopulmonary bypass, because the heart cannot pump blood during surgery.
  • Codes 33463-33464 (tricuspid valvuloplasty) do not include cardiopulmonary bypass.
  • Percutaneous valvuloplasty of the mitral valve is reported 92987; the same procedure for the pulmonary valve is reported 92990.
Coronary Artery Bypass Grafts (CABG) (33510-33548)
  • CABG is performed to bypass blockages in the coronary arteries to improve blood flow.
  • Arterial or venous grafts are harvested from the patient to be used as conduits to the coronary arteries.
  • CPT divides codes by venous, arterial, and combination arterial-venous.
  • If only venous grafting is performed, 33510-33516 (Coronary Artery Bypass: Venous Grafts) is applicable.
  • If arterial grafting is performed, 33533-33536 (Coronary Artery Bypass: Arterial Grafts) is applicable.
  • If both arterial and venous grafting are performed, two codes must be reported from code ranges +33517-+33523 (Coronary Artery Bypass: Venous AND Arterial Grafts - these are add-on codes) and 33533-33536 (Coronary Artery Bypass: Arterial Grafts).
  • The codes indicate the number of the specific type of graft.
  • For example, CPT code 33512 describes a three-venous-graft CABG, and CPT code 33534 describes a two-arterial-graft CABG.
  • If two arterial grafts and two venous grafts are used for bypass, report 33534 for the two arterial grafts and add-on code +33518 for the two venous grafts.
  • You must know which arteries and veins were harvested for the grafts; some harvesting is reported separately, and some are bundled.
  • According to CPT, most arteries and the saphenous vein harvested are bundled into the code set.
  • Harvesting may be reported separately with an additional code to report the extra work involved, for the following:
    • upper extremity artery (e.g., radial): 35600 (open) or 33509 (endoscopic)
    • upper extremity vein: 35500 (open) or 33508 (endoscopic)
    • femoropopliteal vein: 35572 (open) or 33508 (endoscopic)
  • A sequential graft is sometimes used for CABGs.
  • When a sequential graft is used, count each anastomosis (contact point).
  • For example, the left internal mammary artery is anastomosed to the ramus, the diagonal, and the left anterior descending. This sequential arterial graft counts as three arterial grafts (33535).
  • In the illustration, a vein graft is anastomosed to the obtuse marginal and the left circumflex; this counts as two vein grafts (33518).
  • Whether the patient has had a previous CABG is important for several reasons:
    • ICD-10-CM may be different if the patient has atherosclerosis of native coronary arteries (I25.1-) versus previous bypass grafts (I25.7-).
    • Add-on code +33530 is coded for additional reimbursement for reoperation CABG or valve procedures performed more than one month after the original procedure.
  • Do not use HCPCS Level II coronary artery modifiers (LC, LD, and RC) to identify the bypass graft placement. These modifiers are used to indicate the specific vessel involved in percutaneous coronary artery procedures 92920-92944.
Bypass Graft (35500-35683)
  • These grafts are performed on non-coronary vessels.
  • There are three sections: Vein, In Situ Vein, and Other than Vein.
  • You must know the anastomosis sites (where the graft is connected on the ends).
  • For example, if a synthetic bypass graft is placed from the femoral artery to the popliteal artery, report 35656.
  • In situ graft is used for revascularization of lower and upper extremities to avoid amputation.
  • Codes 35583-35587 are for use of venous material alone and are reported for the lower extremities.
  • The saphenous vein is isolated but left in its original position, and vessel clamps are affixed above and below the site of the anastomosis. All side branches are tied off.
  • The valves inside the vein are stripped to allow arterial blood flow toward the foot. The upper and lower ends of the saphenous vein are connected to the arteries (for example, femoral artery and popliteal artery), creating a new circulatory pathway.
  • Codes 35601-35671 are reported for bypass performed on the upper and lower extremities with the use of synthetic vein (prosthetic) material for the grafting.
  • Add-on code +35681 is reported when the graft is composed of autogenous vein and prosthetic graft.
  • Add-on codes +35682-+35683 report harvest and anastomosis of two or more vein segments from distant sites, from a limb other than that undergoing bypass.
  • Any venipuncture, arterial punctures, and closures of surgical wounds are considered inherent to these procedures.
  • Any additional procedures performed to improve blood flow (toward or away from the graft site), as well as intraoperative angiograms, are considered inherent.
  • Harvesting of the saphenous vein is included in the description of 35501-35587.
  • To report harvesting of a femoropopliteal vein segment, use add-on code +35572.
Endovascular Repair of Abdominal Aorta and/or Iliac Arteries (34701-34834)
  • An endovascular abdominal aortic repair (EVAR) involves open femoral or iliac artery exposure and then access with a device manipulated and positioned and deployed, leaving the endograft to repair the abdominal aortic pathology, which includes aneurysm, pseudoaneurysm, dissection, penetrating ulcer, or traumatic disruption in the infrarenal abdominal aorta with or without extension into the iliac artery(ies).
  • The codes are selected based on the vessel the procedure is performed on, the type of endograft, and whether the vessel has ruptured.
  • Procedures on a ruptured vessel are more complicated than procedures without because they involve acute hemorrhage.
  • The infrarenal aortic endografts include an aortic tube device, a bifurcated unibody device, a modular bifurcated docking system with docking limb(s), or an aorto-uni-iliac device.
Central Venous Access Procedures (36555-36598)
  • Central venous access devices (CVAD) are catheters placed in large veins for patients who require frequent access to the bloodstream.
  • The tip of the catheter must terminate in the subclavian, brachiocephalic, or iliac veins to qualify as a CVAD.
  • There are five code categories: insertions, repairs, partial replacements, complete replacements, and removals.
  • The devices may be inserted centrally or peripherally.
  • Central insertion is into the jugular, subclavian, or femoral veins, or the inferior vena cava.
  • Peripheral insertion is into the basilic, cephalic, or other peripheral veins.
  • The devices may be tunneled or non-tunneled and may be accessed via an exposed catheter or a subcutaneous port or pump.
  • If an existing CVAD is removed and a new one placed via a separate venous access site, report both the removal of the old device and insertion of the new device