When coronary arteries clog with plaque (arteriosclerotic coronary artery disease [ASCAD]), the flow of blood is lessened. Figure 6-1 is a drawing that was placed in the patient’s medical record by the cardiologist to indicate the blockage of the patient’s heart vessels. Note that the figure indicates the percentage of blockage of the involved vessels. For example, the right coronary artery (RCA) is 100% blocked by plaque. Figure 6-2 illustrates an artery on fluoroscopy that is blocked with plaque. The heart muscle may begin to function below normal levels—reversible ischemia. If the heart muscle is denied adequate blood flow for an extended period, the muscle may die—irreversible ischemia.

FIGURE 6–1 The percentages indicate the amount of blockage of the patient’s heart vessels. The right coronary artery (RCA) is 100% blocked by plaque.

A coronary artery bypass graft (CABG) bypasses the clogged area(s) of the vessels to improve blood flow. There are three types of coronary artery bypass grafts:

1. CABG with venous graft only (33510-33516)

2. CABG with venous and arterial grafts (33517-33523) and (33533-33536)

3. CABG with arterial graft only (33533-33536)

The heart has two main coronary arteries—the left (left main) and right (right coronary artery). The left main (LM) artery divides into the left anterior descending (LAD) and left circumflex (LCA) arteries (Figure 6-3). The right coronary artery (RCA) supplies the right ventricle and continues down the back of the heart (posterior aspect), where it is called the posterior descending artery (PDA). The coronary artery can be bypassed with an artery using the internal mammary artery, gastroepiploic artery, epigastric artery, radial artery, and arterial grafts from other areas. Note in Figure 6-3 that the internal mammary artery (originates from the subclavian artery) is left attached to the subclavian artery on one end, and the distal end is detached from its origin and reattached to the coronary artery to bypass the area of damage. Other times, the surgeon removes a portion of a vein and uses it for a graft, such as a right or left saphenous vein that is removed and used for a bypass graft. The procurement of the artery or vein is included in the CABG code and would not be reported separately. If an upper-extremity artery, such as the radial artery, is harvested for grafting, however, the harvesting service can be reported separately with 35600 (Harvest of upper extremity artery, one segment for coronary artery bypass procedure) or harvesting of an upper-extremity vein can be reported separately with add-on code 35500 (Harvest of upper-extremity vein, one segment for lower extremity or coronary artery bypass procedure).

Codes are selected based on the type (venous or arterial) of graft (harvested) and the number of grafts placed on the coronary artery (recipient). The number of grafts is determined by counting the number of distal anastomoses where the bypass graft is sutured to the diseased artery. For example, RCA and LAD receive two saphenous vein grafts. The type of graft is venous (harvested), and there were two grafts: one placed on the right coronary artery and one placed on the left anterior descending artery (recipients). The physician will often refer to the harvested and recipient, so you will need to know these terms to interpret the service provided correctly.

A CABG with venous and arterial grafts (33517-33530) is never used alone but only with the arterial graft codes (33533-33536). You can use the arterial graft codes alone (33533-33545) and the venous codes alone (33510-33516), but you can never report the Combined Arterial-Venous Grafting for Coronary Bypass codes alone. A helpful hint is to write “combination AV only” next to the codes 33517-33530 in your CPT manual as a reminder that these codes are used to report the venous graft(s) only when a combined arterial-venous graft is performed. Note that the codes from range 33517-33530 have a plus sign in front of them that indicates add-on codes and are never reported alone.

Cardiovascular surgeons often use artificial materials, such as Gore-Tex, to repair damaged areas of vessels. This artificial material is less susceptible to rejection and calcification than human tissue and can be readily available. The surgeon uses this material to repair a hole in a vessel as a seamstress would apply a patch to a hole in a pair of jeans. The material is cut to size and sewn over the hole. These artificial materials can also be formed into a tube and inserted into a vessel as a support for weakened or collapsed vessel walls.

CASE 6-2 6-2A Coronary Artery Bypass

CASE 6-2

Code the following CABG. Be certain to identify the number, location, and type of grafts.

6-2A Coronary artery bypass

LOCATION: Inpatient, Hospital

PATIENT: Manuel Lopez

SURGEON: David Barton, MD

PREOPERATIVE DIAGNOSIS: Atherosclerotic heart disease

POSTOPERATIVE DIAGNOSIS: Same

PROCEDURE PERFORMED: Coronary artery bypass grafts × 4 with left internal mammary artery to left anterior descending bypass and sequential saphenous vein bypass from the aorta to the first and second obtuse marginal branch of the left circumflex with an ongoing graft to the posterior descending coronary artery.

ANESTHESIA: General

INDICATIONS: This 62-year-old Hispanic male with a history of degenerative knee disease was considered a candidate for orthopedic surgical management; however, preoperatively he underwent stress testing, which was equivocal but prompted angiography, which showed severe three-vessel disease with normal ventricular function.

FINDINGS AT SURGERY: The vein was a 4-mm (millimeter)-diameter vessel of good quality and was used in reverse fashion. The left internal mammary artery was a 1.5-mm-diameter vessel of good quality. The left anterior descending was a 2-mm-diameter vessel of good quality. The first and second obtuse marginal branches were both 2 mm in diameter and of good quality. The posterior descending was, likewise, 2 mm in diameter and of good quality. All the grafts were appropriate prior to closure and were placed distal to palpable disease.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position. With the patient under general intubation anesthesia, the anterior chest, abdomen, and legs were prepped and draped in the usual manner. A segment of the greater saphenous vein was harvested from the left thigh using the endoscopic vein-harvesting technique and prepared for grafting. The pericardium was incised sharply and a pericardial well created. The patient was systemically heparinized and placed on single right atrial-to-aortic cardiopulmonary bypass with a stump in the main pulmonary artery for cardiac decompression. The patient was cooled to 26° C and, on fibrillation, aortic cross-clamp was applied and potassium-rich cold crystalline cardioplegic solution was administered through the aortic root with satisfactory cardiac arrest. Subsequent doses were given down the vein graft as the anastomosis was completed and also via the coronary sinus in a retrograde fashion. The end of the greater saphenous vein was then anastomosed to the proximal third of the posterior descending coronary artery using 7-0 Prolene. The graft was brought to the patient’s left and then anastomosed side to side to the second obtuse marginal branch, followed by the first obtuse marginal branch, all with 7-0 continuous Prolene. The left internal mammary artery was then brought down to the midportion of the left anterior descending and anastomosed thereto with 8-0 continuous Prolene. The aortic cross-clamp was removed after 62 minutes with spontaneous cardioversion to a normal sinus rhythm. The patient was then warmed to 37° C esophageal temperature, during which time the vein graft was trimmed to size and anastomosed to the ascending aorta using 5-0 continuous Prolene technique. The patient was weaned from cardiopulmonary bypass without difficulty using no inotropes after 99 minutes. The patient was decannulated, protamine was given, and hemostasis was obtained. Temporary pacer wires were placed from the right atrium and right ventricles. The chest was drained with two Argyle chest tubes and closed in layers in the usual fashion. The leg was closed similarly. Sterile compression dressings were applied. The patient returned to the surgical intensive care unit in satisfactory condition. Sponge and needle counts were correct × 2.

6-2A:

SERVICE CODE(S): ______________________________________

ICD-10-CM DX CODE(S): ___________________________________

ICD-9-CM DX CODE(S): ___________________________________

From the Trenches

“[The most rewarding part about being a medical coder is] job security, income, networking, and variety.”

ROBERT

Pacemaker

A pacemaker is an electrical device that is inserted into the body to shock the heart electrically into regular rhythm. The two parts of a pacemaker are the battery and electrode. The electrode is the device that emits the electrical charge. The electrode is also called the lead and is a flexible, thin tube. The battery is also called a pulse generator. Some generators are programmable and have a wide range of programming options. The pulse generator is placed into a pocket either under the clavicle, as illustrated in Figure 6-4, or under the muscle of the abdomen below the rib cage.

Either an epicardial or transvenous approach can be used to implant the electrode portion of the pacemaker. The epicardial approach involves opening the chest to the view of the surgeon and the device being placed on the heart. The transvenous approach is most commonly used because it is the least traumatic to the patient and involves inserting a needle with a wire attached (guidewire) into a vein. The guidewire then directs the placement of the electrode into the heart while the surgeon views the progression using a fluoroscope. The electrode is then attached to the pulse generator.

The pacemaker can be a single- or dual-chamber unit. A single-chamber pacemaker uses one pulse generator and one electrode, which is placed in either the atrium or the ventricle. A dual-chamber pacemaker uses a pulse generator and two electrodes—one placed in the atrium and the other placed in the ventricle.

Pacemakers can be permanent or temporary. A temporary pacemaker can be used when the heart needs only short-term pacing support. For example, when a patient is waiting for placement of a permanent pacemaker or a patient is experiencing postsurgical cardiac instability. After the pacemaker is placed, the physician will test the device to ensure that it is operating correctly. The pacemaker implantation report will include a statement such as “thresholds were obtained and were adequate.” The testing and setting are included in the implantation service and are not reported separately. Special or extensive pacing, if noted in the report as being above the usual service, can be reported separately.

A cardioverter-defibrillator is an implantable electronic device that has both the pulse generator and the electrodes, but it is capable of more functions than the pacemaker. The device senses irregularities in the heart rhythm and emits electrical charges to regulate the heart rhythm and pace the heart to correct heart rhythm. The device can be programmed to sense a wide variety of heart irregularities and then further programmed to emit various electrical charges in response. The device is used for antitachycardia (stops rapid heartbeat) pacing, low-energy cardioversion (restoration of normal heartbeat), or defibrillating shocks to treat tachycardia or fibrillation (quivering).

A single-chamber cardioverter-defibrillator has a lead or leads inserted into a single chamber; a dual-chamber cardioverter-defibrillator has leads inserted into both the atrium and ventricle. The number of leads used does not indicate a single- or dual-chamber cardioverter-defibrillator because when a single chamber is being paced, multiple leads into that single chamber may be used. It is the number of chambers into which the leads are placed, not the number of leads used, that impacts code choice.

During insertion, electrophysiologic testing of a cardioverter-defibrillator and electrical analysis of a pacemaker would often be conducted as a part of the insertion or reinsertion procedure. This testing and analysis would be reported separately using Medicine section codes 93279-93285. Perioperative testing is also reported separately with Medicine section codes 93286 and 93287. Remember to use modifier -26 if you are reporting only the professional component (physician) of the electrical analysis.

When a pacemaker or cardioverter-defibrillator battery is changed, it is actually the pulse generator that is replaced. As a part of the usual 90-day surgical package that accompanies the implantation service, follow-up visits would be considered part of the global service by the third-party payer and therefore not reimbursed.

Removal of only the pulse generator without insertion of a new pulse generator is reported with 33233 or 33241. If the pulse generator is replaced without insertion or replacement of transvenous electrode(s), both the removal and insertion of another pulse generator is reported with only one code. 33227-33229 (permanent pacemaker) or 33262-33264 (cardioverter-defibrillator), depending on the lead system number already in place. Removal and replacement of a permanent pacemaker pulse generator and transvenous electrode(s) is reported with 33233 in addition to 33234 or 33235 and 33206-33208. Removal and replacement of a cardioverter-defibrillator pulse generator and transvenous electrode(s) is reported with 33241 in addition to 33243 or 33244 and 33249.

Sick sinus syndrome

Sick sinus syndrome is a group of abnormal heartbeats (arrhythmias). The exact cause of this syndrome is unknown, but it is thought to be caused by a malfunction of the sinus node, which is the heart’s natural pacemaker. It can result in many arrhythmias, including tachycardia (fast heart rate), bradycardia (slow heart rate), sinus arrest, sinus node exit block, and sinus bradycardia. These arrhythmias are not reported separately because they are symptoms of the syndrome. Rather, the syndrome is reported. You can locate direction to the code in the Index by referencing “Syndrome, sick, sinus.”

CASE 6-3 6-3A Cardiology Follow-Up Note

CASE 6-3

With the information you just learned about pacemakers, code the following E/M services to a patient who, after several tests, will have a pacemaker implanted.

6-3A Cardiology follow-up note

LOCATION: Outpatient, Clinic

PATIENT: Herbert Gillford

PHYSICIAN: Marvin Elhart, MD

DIAGNOSES:

1. Symptomatic sick sinus syndrome

2. Dementia

3. Dilated cardiomyopathy with previous history of congestive heart failure

MEDICATIONS: Tylenol; Lasix 40 mg (milligram) as needed; Vasotec 5 mg once daily; Colace; aspirin: Ambien; and Arthrotec.

I evaluated this patient approximately 2 years ago. He was seen by Dr. Pleasant again last year on referral from Dr. Green because of episodes of falling down. The episodes are significant to the point that he had a hip fracture. Apparently, he was transferred to a nursing home in his hometown.

The history from the patient is almost useless because he does not recollect any symptoms and he says he feels fine and has no shortness of breath or falling down. The patient has been diagnosed with dementia previously. We tried to contact his relative, but we got the answering machine.

We reviewed the previous notations from Dr. Green and Dr. Pleasant and myself. Predominantly the problem is that the patient has had repeated falls and has been diagnosed with sinus bradycardia with first-degree AV (arteriovenous) block and bundle-branch block; a Holter monitor read by myself recently revealed predominantly atrial block.

EXAMINATION today reveals an elderly man in a wheelchair in no acute distress. His blood pressure was 124/68 with a heart rate of 60. Lungs did not reveal any rales. Cardiovascular examination reveals distant heart tones with normal S1 (first heart sound) and S2 (second heart sound) with a holosystolic murmur, grade 1/6, over the mitral area. Abdomen was obese. Extremities: No edema.

ECG (electrocardiogram) in the office reveals him to be in sinus bradycardia with a rate of 49 with first-degree AV block and left bundle-branch block. The Holter monitor revealed him to be predominantly in atrial fibrillation; his minimum rate was 49 and maximum 114 with an average of 74. At that time, the notation did show that he was taking Lanoxin, which apparently he is not taking at this time.

An echocardiogram also read by myself revealed the patient to have dilated cardiomyopathy with severe LV (left ventricle) dysfunction with mild aortic insufficiency and significant mitral insufficiency.

IMPRESSION AND RECOMMENDATIONS: Symptomatic sick sinus syndrome with evidence of paroxysmal atrial fibrillation. It is very difficult to assess this patient symptom-wise because he does not have a lot of insight into his symptoms. He has been diagnosed with dementia. It seems to me that there is enough evidence that this patient’s falling down episodes might be related to his rhythm because that is the most common finding. The only solution to this problem would be implantation of a dual-chamber pacemaker.

We attempted to contact his family to discuss this and to obtain a consent, but we did not get an answer. We will contact the family again and discuss with them the recommendations. If they consent to it and agree to proceed, we will bring him in for implantation of a dual-chamber pacemaker.

6-3A:

SERVICE CODE(S): ______________________________________

ICD-10-CM DX CODE(S): __________________________________

ICD-9-CM DX CODE(S): ___________________________________

In reports 6-5B and 6-5C, you will be coding the pacemaker implantation for the patient in report 6-3A, but you must learn a couple more things before you code the implantation service. Let us begin with echocardiography services.

Echocardiography

Cardiomyopathy (CMP) is a disease of the heart muscle. The exact cause(s) of cardiomyopathy are not known, and the symptoms of the disease are similar to those displayed in patients with myocarditis (infections of the heart muscle caused by virus, bacteria, or parasites), toxic effects of various drugs, myocardial infarction, various cardiac disorders (pericarditis, congestive heart disease, or stenosis), and various other conditions. As a part of the diagnostic process, the physician may order an electrocardiogram, chest x-rays, Doppler and echocardiography, radionuclide studies, cardiac catheterization, or blood tests.

Echocardiography obtains ultrasonic signals from the heart and coronary arteries with a two-dimensional image and/or Doppler ultrasound. Transthoracic echocardiography is a noninvasive procedure in which a transducer (transmitter) is placed on the skin and sound waves go through the structure of the body and bounce off the heart. From the frequency with which the waves return from the internal structures and bounce back to the transducer, the physician can determine the position and motion of the heart walls and internal structures of the heart and neighboring tissue.

Transesophageal echocardiography (TEE) is a procedure in which the transesophageal echography probe transducer is placed into the mouth and advanced into the esophagus, allowing a posterior view of the heart, as illustrated in Figure 6-5. Varieties of TEEs are reported with codes 93312-93318. The codes are divided into those done for congenital cardiac conditions (93315-93317) and those done for noncongenital cardiac conditions (93312-93314). The stand-alone codes 93312 and 93315 are for the full service, and the indented codes are for components of the service. For example, 93313 is used to report the placement of the transesophageal probe only. Code 93318 is used to report a TEE for monitoring purposes. These monitoring functions are not limited to monitoring of the heart but also include monitoring of numerous organs, such as the lungs and mediastinum. These monitoring services are not the usual diagnostic service but instead are urgent services that are required for a critically ill or injured patient. (In Case 6-14A, you will be coding a TEE service prior to a cardioversion.)

FIGURE 6–5 Transesophageal echocardiography (TEE).

Doppler echocardiography is a technique that records the flow of blood through the cardiovascular system by tracking the movement of the red blood cells by ultrasound. The pulsed-wave or continuous-wave Doppler produces a video recording or strip chart detailing the force with which the blood passes through the cardiovascular system and the direction of the blood. A color-flow Doppler is similar to the pulsed-wave or continuous Doppler, but in addition to the color flow is a two-dimensional color display. The color makes identification of blood flow easier. Code 93306 is a complete transthoracic echocardiography that includes M-mode, when performed, and spectral and color-flow Doppler. A limited transthoracic echocardiography, without spectral and color-flow Doppler, is reported with 93307. Note that you cannot report 93320 (complete Doppler), 93321 (limited Doppler), or color-flow velocity mapping (93325) with 93307.

Valve insufficiencies

Insufficiency of a heart valve means the valve does not close properly, which may lead to hypertrophy (enlargement) of the heart because blood will pool in the chambers. Rheumatic heart disease is a result of rheumatic fever, which is a febrile (fever) disease caused by a streptococcal infection and results in valvular deformities. The ICD-10-CM/ICD-9-CM divides codes for nonrheumatic valvular insufficiencies from valvular insufficiencies that are a result of (sequela) rheumatic heart disease. Category I34/424 is for nonrheumatic or other specified causes. This code is also assigned for unspecified causes when only one valve is involved. The documentation is often aortic stenosis (I35.0/424.1) of unknown cause. When there are multiple valves involved in the diagnosis or the documentation specifies rheumatic, refer to I05/394 to I08/396. For example, a commonly documented diagnosis is aortic and mitral valve regurgitation (not specified as rheumatic), which is reported with I08.0/396.3. When both mitral and aortic valves are involved, the ICD-10-CM/ICD-9-CM presumes an etiology (cause) of rheumatic heart disease, and the physician does not need to document rheumatic heart disease. Also, when the diagnosis involves the tricuspid valve, the etiology also is presumed to be rheumatic heart disease if multiple heart valves are involved. In ICD-9-CM insufficiency of the pulmonary valve (424.3) is not considered to be rheumatic when other heart valves are also involved unless stated as rheumatic (397.1).

CASE 6-4 6-4A Echocardiogram

CASE 6-4

The patient presented to Dr. Elhart with complaints of chest discomfort. A 2-D Doppler and color-flow Doppler were performed at the local hospital in the outpatient cardiology department, and Dr. Elhart monitored the echocardiography.

6-4A Echocardiogram

LOCATION: Outpatient, Hospital

PATIENT: Herbert Gillford

PHYSICIAN: Marvin Elhart, MD

STUDY: The study is 2-D and a color-flow Doppler echocardiography.

INDICATION FOR STUDY: Sinus bradycardia

Chamber dimension by M-mode:

1. The left atrial diameter is 62 mm (millimeter), which is consistent with moderate atrial enlargement.

2. The aortic root is 39 mm.

3. Left ventricular diastolic diameter is 75 mm; systolic diameter is 65 mm.

4. Shortening fraction is 13%.

5. Ejection fraction is estimated at 26%.

6. Wall thickness is 7 mm.

DOPPLER:

1. Mild aortic insufficiency. The peak velocity across the aortic valve was estimated at 2 m/second. There is no evidence of significant aortic stenosis.

2. There is eccentric jet of mitral insufficiency. The E-velocity is estimated at 1.1 m/second, and that certainly corresponds with severe mitral insufficiency. There did not appear to be any significant mitral stenosis, even though the opening was decreased due to low cardiac output state.

3. There is moderate tricuspid insufficiency. The RV (right ventricle) systolic pressure could not be estimated because of incomplete spectral envelopes.

4. Mild pulmonary insufficiency without stenosis.

2-D ECHO (ECHOCARDIOGRAM):

1. Mild to moderate left ventricular enlargement. The overall left ventricular systolic function is severely depressed, and ejection fraction is estimated at 15% to 20%.

2. There is severe global hypokinesia. The inferoposterior segment appears to be akinetic. The wall thickness is normal.

3. Right ventricle, right atrium, and aortic root are within the normal limits. The left atrium is moderately dilated.

4. The mitral valve is minimally thickened, and the excursion is decreased and most likely is due to low cardiac output state rather than mitral stenosis. The aortic valve is fibrocalcific without significant stenosis. The tricuspid valve is unremarkable.

5. There is no pericardial effusion.

CONCLUSION:

1. This is a markedly abnormal echocardiogram that reveals the presence of mild to moderate left ventricular enlargement with severe global left ventricular systolic dysfunction due to valvular insufficiency.

2. Mild aortic insufficiency.

3. Severe mitral insufficiency.

RECOMMENDATIONS:

1. I would suggest aggressive medical therapy with the use of ACE inhibitors, diuresis, and possible ACE inhibitors. SBE (subacute bacterial endocarditis) prophylaxis.

6-4A:

SERVICE CODE(S): ______________________________________

ICD-10-CM DX CODE(S): __________________________________

ICD-9-CM DX CODE(S): ___________________________________

Case 6-4A Discussion

This patient was referred for the symptom of sinus bradycardia (R00.1/427.89); but there are more definitive diagnoses available based on the test results. In the Conclusion section of the report, the physician indicates “left ventricular enlargement with severe global left ventricular systolic dysfunction due to valvular insufficiency.” The ventricular enlargement and dysfunction are “due to” another more specific condition (valves are not functioning properly) and therefore neither the enlargement nor the dysfunction are reported separately. The physician indicated both aortic and mitral insufficiency and, in the Doppler section of the report, he indicated tricuspid and pulmonary insufficiency. No specific cause for these conditions was specified, so each of the conditions must be reported.

ICD-10-CM: There are two codes required to report these diagnoses. In the Index of the ICD-10-CM, reference the main term “Insufficiency” and subterms “mitral, with, aortic valve disease”, which is coded to I08.0; however, “tricuspid [valve] disease” is also documented. A combination code describing combined rheumatic disorders of mitral, aortic, and tricuspid valves is assigned. Although documentation does not indicate that the multiple valve diseases are rheumatic in nature, the “Includes” note under category I08 states that this category also includes multiple valve diseases that are unspecified, therefore, I08.3 is assigned. In the “Doppler” section of the report, the physician indicates that the patient also has tricuspid and pulmonary insufficiencies. The pulmonary valve insufficiency is reported with I08.8.

ICD-9-CM: There are three codes required to report these diagnoses—one code for each of the insufficiencies. In the Index of the ICD-9-CM, reference the main term “Insufficiency” with subterms “mitral, with aortic valve disease” to be directed to the Tabular to reference 396.3. Reference “Insufficiency, tricuspid” to be directed to refer to the Tabular code entry 397.0. The Index for “Insufficiency, pulmonary, valve” refers you to 424.3. The Tabular for 424.3 indicates “insufficiency NOS” and “Excludes that specified as rheumatic (397.1)”, indicating this is the correct code to assign to this pulmonary valve insufficiency.

Holter

Another commonly used cardiac diagnostic tool is the Holter monitor, which is a portable electrocardiography device that is worn by the patient, usually for 24 hours but up to 48 hours. The monitor records the electrical function of the heart and allows the physician to analyze the data to diagnose various cardiac conditions.

The sequence of events is important to know before you code the Holter monitor service. When the patient’s physician evaluates the patient and determines that the patient requires the monitoring of cardiac function by means of a Holter monitor, the physician orders the monitoring, and at a later time the patient presents to the cardiology laboratory to be fitted with a monitor. The technician, under the supervision of the cardiologist, outfits the patient with the monitor, and the patient leaves the department wearing the monitor for a specified period of time (usually 24 to 48 hours for a Holter). The patient returns to the cardiology department, and the technician removes the monitor. The cardiologist interprets tracing of the Holter and writes a report of findings that is sent to the physician who ordered the monitoring. In the meantime, after the monitoring has been performed, but before the results are returned and reviewed by the physician, the coder reports the services. This sequence is important in identifying the diagnosis for which the services were provided. The coder does not wait for the results of the various tests to be returned before reporting the services for reimbursement. The coder does, however, wait for the test to be conducted prior to submitting for reimbursement. The physician’s diagnosis will be used to report the services for the Holter monitoring in the following report. After the physician reads the report, he or she may change the diagnosis of the patient to reflect the test results, but only the physician can make the determination of the diagnosis. Perhaps the physician ordered several tests and the interpretation as to the diagnosis varied. It is the ordering physician’s responsibility to assess all test results and make the conclusion as to the final diagnosis. When coding the various reports in this text, you will be seeing the report results. However, you would usually only know that the test had been requested and performed, not the results.

CASE 6-5 6-5A Holter Report 6-5B Radiology Report, Preimplantation 6-5C Operative Report, Pacemaker Implantation 6-5D Radiology Report, Postimplantation

CASE 6-5

6-5A Holter report

Code the following Holter service, assuming the test had been ordered and performed. Report the global service. For the diagnosis, you would use the information presented in the “Indication” section of the report, because that would be the reason the physician ordered the test.

LOCATION: Outpatient, Clinic

PATIENT: Herbert Gillford

PHYSICIAN: Dr. Marvin Elhart

INDICATION: Patient with atrial fibrillation on Lanoxin. Patient has known cardiomyopathy.

BASELINE DATA: An 86-year-old man with congestive heart failure who is taking Elavil, Vasotec, Lanoxin, and Lasix.

The patient was monitored for 24 hours during which time the analysis was performed.

INTERPRETATION: