# Tavr - I am needing to know what



## Rosanat1991 (Mar 20, 2015)

I am needing to know what we can bill in addition to the code for the TAVR.

PREPROCEDURE DIAGNOSES:
1.  Congestive heart failure, acute on chronic, diastolic heart failure with ejection fraction of 65%.
2.  Symptomatic critical aortic valve stenosis.
3.  History of mild coronary artery disease.
4.  History of advanced age and deemed high risk for traditional surgical intervention
5.  S/P recent BAV
6.  Renal insufficiency
7.  Right pleural effusion

POSTPROCEDURE DIAGNOSES:
1.  Successful 29-mm Edwards Sapien transcatheter aortic valve replacement through left common femoral artery.
2.  Pericardial Tamponade
3.  Temporary pacemaker perforation
4.  s/p emergent pericardiocentesis
5.  Transient Atrial fibrillation
6.  Mild-to-moderate systolic and diastolic dysfunction.
7.  S/p emergent stenrotomy with closure of RV perforation

PROCEDURES:
1.  Access right femoral artery with 6 Frenchs sheath
2.  Right femoiral vein with 6 French sheath
3.  Access left femoral artery using cut down technique (Dr. 3 and Dr. 4)
4.  Temporary pacemaker implantation via right femoral vein 
5.  Aortic root angiogram x3 (1 x pre and 2x post BAV)
6.  Left heart catheterization
7.  Ballon aortic valve valvuloplasty pre TAVR
8.  Placement of 29-mm Edwards Sapien transcatheter aortic valve replacement via the left common femoral artery.
9.  Emergent pericardiocentesis (Dr. 2)
10. Placement of pericardial drain (Dr. 2)
11.  Emergent sternotomy by Dr. 3 adn 4
12.  Manual hemosatsis 

INDICATION FOR PROCEDURE:
The patient is a pleasant 90-year-old frail male with history of mild CAD and significant dyspnea and DOE who had BAV at SGH last month.  He was seen by Dr. 3 and Dr. 4 and was deemed appropraiate for TAVR over open procedure.  He has had moderate AI since his BAV.  


DESCRIPTION OF PROCEDURE:

ACCESS: The patient was brought to cardiac catheterization laboratory in a fasting state.  The whole patient including the bilatral groins were prepped and draped in usual sterile fashion.  A 20 mL of 2% lidocaine was used to anesthetize the right femoral area.  

A 6-French sheath  was placed in the right femoral artery using modified Seldinger technique.  A 6-French sheath was placed in the right common femoral vein using modified Seldinger technique.  

PACEMAKER:  A 5-French balloon tip temporary pacemaker failed to cross into the RV.  We then used a stiffer 6 Fr regular pacemaker via the right femoral vein.  GIven difficulty getting PM in position. Dr. --- was able to position pacer in right ventricle, placed on backup pacing with adequate sensitivities and threshold.  

Before the Aortogram, we did note the pressure was transiently low.  But this resolved. 

AORTOGRAM:  Then, a 5-French pigtail catheter was positioned in the right coronary cusp and aortic root angiogram was then performed using 10 cc contrast in the LAO 5 and caudal 4 degrees to evaluate position and to evaluate for aortic insufficiency or dissection.

BAV: The patient had been on heparin with a therapeutic ACT.  We achieved a greater than 250 ACT throughtout. Cutdown had already been performed in the left femoral area by Dr. 3 and Dr. 4 to be dictated separately.  

Then positioned 20-French Edwards sheath in the left femoral artery using modified Seldinger technique after predilating with a 16-French and then a 20 French dilator, positioned initially Meier wire to deliver the sheath, then used an AL1 catheter to cross the aortic valve with a straight stiff Glide wire, then a J-wire, positioned a pigtail catheter in the left ventricle.  Left heart catheterization was then  performed in the left ventricle and placed.  Pressure was recorded.  Pigtail catheter was then removed over an extra stiff Amplatz wire.  Balloon valvuloplasty was then performed with a 23-mm Edwards balloon for 3 seconds.  

We then tested PPM and would not capture. Then Dr. 2 was able to remaninpulate and position this with capturing. 

TAVR:  Balloon was deflated, reevaluated with TEE showing more moderate aortic insufficiency,  advanced a 29-mm Edwards Sapien transcatheter aortic valve in the aortic position.  Performed root angiography under rapid pacing at 150 bpm and off ventilation,  then deployed the valve without any difficulties.

We then noted that the patient had low BP.  The hear rate recovered with rapid SVT then atrial fibrillation but the BP did not recover despite temporary pacemaker at 80.  The TEE showed depressed LV function with small pericardial effusion.

An Aortogram showed patent RCA and LMCA with minimal AI.  We then noted expanding pericardial effusion.  We quickly concluded that a temporary pacemaker perforation was likely.  We quickly proceed with pericariocentesis (see Dr. 2's note).

After protamine for reversal, we removed the left femoral 20 French Edwards's sheath and the cutdown was repaired.  Simulatenously we were evacuating blood from the pericardium.  We then noted reaccumulation of the pericardial effusion and thus, with further drop in BP, Dr. 3 and Dr.4 proceeded with stenotomy and closure of an identified inferior wall of RV perforation.  The temporary pacemaker was removed.  

Thanks in Advance,
Paula and Rosana


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## j.monday7814 (Mar 23, 2015)

you can bill for the aortogram evaluation of the right and left main coronaries. I don't think the coronaries were engaged so it's basically 93567 but since that is an add-on code it cannot be billed with the TAVR. 36221 wouldn't work either since there wasn't evaluation of carotids or vertebrals. It is a separate service from the TAVR but there isn't a legitimately good way to bill it.

the pericardial effusion was caused by perforation of the RV, this is a tough choice. Personally I wouldn't bill for it because it was the physician's fault and I think it is bad karma to bill for repairing damage that you cause during a procedure. But technically you could bill for the sternotomy and repair.


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## Misty Dawn (Mar 24, 2015)

Codes for diagnostic left heart catheterization (93452, 93453, 93458-93461) and supravalvular aortography (93567) should NOT be reported with the 
TAVR the codes. A supravalvular aortography is included with these procedures and is necessary for the placement of valve.

PROCEDURES:
1.  Access right femoral artery with 6 Frenchs sheath
** Included/bundled with TAVR 

2.  Right femoiral vein with 6 French sheath
** Included/bundled with TAVR

3.  Access left femoral artery using cut down technique (Dr. 3 and Dr. 4)
**  Included/bundled with TAVR (even though performed by Dr. 3 and Dr. 4 
still can not bill separately. Unfortunately they offered their services for free here. If they are to bill your TAVR claims will deny. (Check your payor but I do not know of any that will reimburse separately for this.) 

4.  Temporary pacemaker implantation via right femoral vein 
**  Included/bundled with TAVR

5.  Aortic root angiogram x3 (1 x pre and 2x post BAV)
**  Included/bundled with TAVR

6.  Left heart catheterization
**  Included/bundled with TAVR

7.  Ballon aortic valve valvuloplasty pre TAVR
**  Included/bundled with TAVR

8.  Placement of 29-mm Edwards Sapien transcatheter aortic valve replacement via the left common femoral artery.
**  Use correct TAVR code for type of access. This can be billed by the two primary providers (of different specialties) with a 62 modifier.  (Note that the 80 modifier is not accepted for these codes.) 

9.  Emergent pericardiocentesis (Dr. 2)
**  Can bill additionally by Dr 2

10. Placement of pericardial drain (Dr. 2)
**  Can bill additionally by Dr 2 

11.  Emergent sternotomy by Dr. 3 adn 4
**  Can bill additionally by Dr. 3 and 4.

12.  Manual hemosatsis 

Included and should NOT be billed separately: 
    Codes 33361-33366 include the work, when performed, of percutaneous access, placing the access sheath, balloon aortic valvuloplasty, advancing the valve delivery system into position, repositioning the valve as needed, deploying the valve, temporary pacemaker insertion for rapid pacing (33210), and closure of the ateriotomy when performed. Also includes open arterial or cardiac approaches. 
     Angiography, radiological supervision, and interpretation performed to guide TAVR/TAVI (eg, guiding valve placement, documenting completion of the intervention, assessing the vascular access site for closure) are included in these codes. 
     Diagnostic LHTC codes (93452,93453,93458-93461) and the supravalvular aortagraphy codes (93567) should not be used with TAVR/TAVI services to report contrast injections, angiography, road mapping, and/or fluoroscopic guidance of the TAVR/TAVI. Aorta/Left Ventricular outflow tract measurement for the TAVR/TAVI or post-TAVR/TAVI aortic or left ventricular angiography, as this work is captured in the TAVR/TAVI services.

CAN be billed additionally: 
     When Cardiopulmonary bypass is performed in conjunction with TAVR/TAVI, report with the appropriate add-on code: for percutaneous peripheral bypass use +33367, Open peripheral bypass use +33368, or Central bypass use +33369. ***Code 33367-33369 for the primary surgeon ONLY.  
     When transcatheter ventricular support is required in conjunction with TAVR/TAVI, the appropriate code should be reported with the appropriate ventricular assist device (VAD) procedure code (33990-33993, 33975, 33999) or balloon pump insertion code (33967, 33970, 33973).  Please see VAD coding memo for coding guidelines. 
     Percutaneous coronary interventional procedures are reported separately, when performed.
     Peripheral interventional procedures are reported separately, when performed. 
     If performed a TEE is separately reportable.
     If performed ICE is separately reportable. 
    Other cardiac catheterization services are reported separately when performed for diagnostic purposes NOT INTRISIC to TAVR/TAVI. 

Diagnostic coronary angiography performed at the time of TAVR/TAVI may be separately reportable if: 
NO prior catheter-based coronary angiography study is available and a full diagnostic study is performed, or 
A prior study is available, but as documented in the medical: 
*The patient?s condition with respect to the clinical indication has changed since the prior study. 
*There is inadequate visualization of the anatomy and/or pathology. 
*There is a clinical change during the procedure that requires a new evaluation. 
For same session/same day diagnostic coronary angiography services, report the appropriate diagnostic cardiac catheterization code(s) appended with the modifier 59 indications a SEPARATE and DISTINCT procedural service from TAVR/TAVI.

Common ICD 9 codes: 424.1, 395.0, 395.2 ,396.8 and 746.3



Misty Sebert CPC, CCC, CCVTC
https://www.linkedin.com/in/mistysebertcardiologycoder


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## j.monday7814 (Mar 24, 2015)

Misty, the diagnostic or mapping aortography is included in TAVR but any change in the patient's condition requiring another or more detailed study is always separately reportable. The pericardial effusion changes everything.


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## Misty Dawn (May 1, 2015)

??? the pericardial effusion does not change anything for the above case-it is an add on code done with no primary code.


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## j.monday7814 (May 8, 2015)

Misty Dawn said:


> ??? the pericardial effusion does not change anything for the above case-it is an add on code done with no primary code.



what? how would a pericardial effusion not change the case?? this is not a common complication of any percutaneous procedure. A pericardial effusion absolutely changes everything, this isn't something they're going to ignore!

I never said that billing 93567 was the right thing to do but pericardial effusion warrants additional imaging and treatment of that condition.


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