# STEMI vs NSTEMI & 92941 vs 92928



## treinemer (Jun 15, 2016)

Having a discussion with HIM vs Pro coders re a patient that was documented as below. HIM is saying this is 92941, Myself and the other Pro coder are saying 92928 because he documented non stemi. We are in a standoff and the provider is not readily available to ask face to face. When asked through management the response was "says it was an acute MI non stemi".

Patient is not medicare.

What is your opinion and why? I tried to find definitive documentation but had trouble coming up with a black and white answer.

Thanks!


_Indications:  Acute chest pain with marked ST segment depression in the inferior leads highly suspicious for acute non-ST segment elevation myocardial infarction


Benefits, alternatives and risks, including the risk of bleeding, MI, stent thrombosis, emergency bypass and death were explained to the patient and informed consent was obtained.


Procedure: Right iliac angiography, Left heart cath, coronary angiography, and complex bifurcation coronary stenting of the acutely occluded mid circumflex and second circumflex marginal, as well as stenting of the proximal main trunk circumflex into the very large first obtuse marginal with final jail break dilatation of the jailed continuation mid circumflex.


The patient was brought to the Cath Lab and was prepped and draped in the normal sterile technique.  The right femoral artery was cannulated and a 6 French sheath was inserted.  We encountered a severe stenosis of the ostium of the right common femoral artery, requiring right iliac angiography and a Versacore floppy wire and 6 French 45 cm flexible braided sheath to safely cannulate the aorta from the right femoral arterial access point.  We used 6 French catheters for right and left coronary angiography and left heart catheterization.  Decision was made to proceed with intervention of the acutely proximally occluded mid circumflex coronary artery.  The acute occlusion, peripheral vessel was involved with bifurcation disease with the proximal circumflex and a huge first obtuse marginal; the acute occlusion, peripheral vessel appeared to be much smaller than the first obtuse marginal.  There was no anatomic visualization that could guide wire placement.  A 6  French JCL 4.5 guide was used to cannulate the left coronary system.  The patient was given to tirofiban and repeated heparin boluses to maintain an activated clotting time greater than 250 seconds..  The lesion was crossed using a run through wire; cannulating the diffusely subtotally occluded second circumflex marginal was highly technically difficult.  There was really no angiographic visualization to guide wire placement, and it was very difficult to find the takeoff of the second circumflex marginal from that AV groove and to stay out of repetitively cannulating the distal AV groove vessel.  The difficulty with finding the second circumflex marginal for wiring added significantly to the contrast load for the procedure.  A protective wire, a prowater guidewire, was placed in the large first obtuse marginal.  A 2.5 x 12 mm tract Rx balloon was utilized to predilate the proximal aspect of the continuation mid circumflex.  Finally, enough opacification of the second circumflex marginal was seen to be able to selectively wire this vessel.  The second circumflex marginal was a small caliber bifurcated vessel supplying a moderate zone of basal inferoposterior myocardium.  There was what appeared to be diffuse disease of this vessel; a 1.5 x 20 mm Apex push balloon was utilized for dilatated to this vessel, which showed that there was diffuse disease up to the takeoff of the superior side branch but that beyond that point, the vessel appeared angiographically relatively healthy.  As a result, stenting of this vessel from immediately prior to its small subbranch origin back to the bifurcation of the circumflex with the major obtuse marginal was carried out; a 2.5 x 15 mm XIENCE Alpine Rx stent was placed more distally, deploying the stent at 6 atm and then retracting the stent delivery balloon slightly and dilating to 15 atm; a 2.5 x 18 mm XIENCE Alpine Rx stent was then placed all the way back to the ostium of the continuation mid circumflex and a minimally overlapping with the already deployed stent in the second obtuse marginal more distally, deploying the stent to 15 atm.  Postdilatation of this vessel was performed utilizing a 2.75 x 20 mm NC Trek balloon to a maximum of 16 atm.  There had been tremendous plaque shift into the extremely large first obtuse marginal and as a result, stenting of the proximal circumflex into the first circumflex marginal across the continuation mid circumflex with jail break in the mid circumflex would now be necessary.  A 4.0 x 12 mm XIENCE Alpine Rx stent was deployed in the proximal circumflex trunk extending into the very large first obtuse marginal after performing intravascular ultrasound of both the mid circumflex and the first obtuse marginal.  The stent was deployed at 15 atm and postdilated with a 4.0 x 8 mm NC trek balloon to 16 atm.  The guidewire had of course been removed from the mid circumflex, and the mid circumflex was now rewired.  Extensive efforts to jail break the mid circumflex were unsuccessful, reported by the mass of stent struts at the ostium of the mid circumflex.  Only a 1.25 x 12 mm sprinter Legend the balloon was able to cross and dilate; multiple efforts were made with a small caliber balloons as well as glider balloons, but all would not cross.  Final angiography was repeated after removal of the guidewires, showing angiographically optimal results with no evidence of edge dissection or lumen compromise, with normal flow throughout.  The patient was moved to the floor in stable condition.  There were no complications.  The procedure was extremely technically difficult due to an inability to adequately visualize the target lesion, the second circumflex marginal, as well as the profound angulation of the circumflex to allow for jail break angioplasty.  These things contributed substantially to the large fluoroscopic dose and contrast dose the patient received.


Hemodynamic / Angiographic Data:   
Left ventriculography:  Not performed; left ventricular end diastolic pressure was 16 mmHg.  There was no gradient upon pullback across the aortic valve.
The left main: Large in caliber and angiographically normal, dividing into the left anterior descending and circumflex coronary arteries; there is a very small ramus intermedius that's probably arose actually from the ostium of the circumflex.
The left anterior descending artery: Moderately large in caliber with only minimal luminal irregularities.  The LAD supplied to slender proximal diagonals and 2 moderate sized diagonals off the mid vessel, then terminated after traversing the apex.
The left circumflex:  Had a severe bend back orientation proximally, where it divided into a left atrial branch, an extremely large first obtuse marginal branch, and the continuation mid circumflex.  The bifurcation had plaque affecting all vessels, with 50% stenosis in the origin of the very large first obtuse marginal and diffuse disease of the continuation mid circumflex, which was acutely occluded shortly thereafter.
The right coronary artery: Large dominant vessel with only mild luminal irregularities, supplying a large posterior descending branch and 3 posterolateral branches.
_


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## dpeoples (Jun 16, 2016)

The term "highly suspicious for" does not support 92941. If the HIM wants to bill 92941, then the document must be amended appropriately. IMO.

HTH


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## Twixle2002 (Jun 20, 2016)

Notes and report should also state patient was brought emergently to cath lab to substaniate a 99241


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## treinemer (Jun 21, 2016)

*Thank you!*

Thanks guys, that was our conclusion but we never could get the hospital side to give. We sent it through correct and they can deal with the denial.


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