# Lt heart cath /IVUS/angio



## CPCCODERII (Feb 24, 2012)

We are new to cardiology coding and have just began to start coding heart catheterizations and have come across a more complicated case.  Can you please look over the documentation we have provided and give feedback regarding code selection.  Also, we are concerned that our provider is not providing sufficient documentation or information on catheter movement and placement for the DSA OF ABD AORTA W/ FLUSH RENAL ANGIO & DSA OF THE TERMINAL AORTA W/ ILIAC ARTERY ANGIO.  The codes we selected for this case are:

93458-26/36245/93571-26/92978-26/93567/G0275 (patient is self pay)

Operative note:
PROCEDURE:
1.  Left heart catheterization via the right common femoral artery (CFA).
2.  Angiography of the left ventricle, coronary arteries, and right CFA.
3.  Intravascular ultrasound (IVUS) in the left main coronary artery (LMCA).
4.  Angiography of the terminal aorta and iliac arteries bilaterally.  
5.  DSA of the abdominal aorta with flush renal artery angiogram. 
6.  Percutaneous closure of the right CFA using Perclose.

IMPRESSION:
1.  Severe atherosclerotic coronary artery disease with 60% obstruction in the ostium of the left main coronary artery.  The ostial plaque was calcified and the obstruction was hemodynamically significant with a distal to proximal mean pressure ratio (estimated FFR) of 0.75 and a lumen area of 5.0 mm by IVUS.
2.  Severe elevation of the left ventricular end-diastolic pressure.
3.  Moderate to severe mitral insufficiency.
4.  Normal LV size.
5.  Mild LV systolic dysfunction, ejection fraction 41%.

INDICATION FOR PROCEDURE:
Acute systolic heart failure with flash pulmonary edema.  LV systolic dysfunction.
Mitral insufficiency.

DESCRIPTION OF PROCEDURE:
Informed consent was obtained.  We discussed the goals, risks and alternatives to proceeding with cardiac catheterization and possible PCI and important differences among PTCA, BMS, and DES.  We discussed the need for dual antiplatelet therapy without interruption, which could prevent or delay other procedures.  In anticipation of a possible need for mitral valve surgery within 1 year, we discussed
the probability of using a bare metal stent instead of a drug-eluting stent, to decrease the required duration of DAT.

DESCRIPTION OF PROCEDURE:
Cardiac catheterization was performed percutaneously via the right CFA using a 6 French 10 cm sheath.  Catheters were exchanged over a guidewire.  A straight pigtail catheter was advanced into the LV for left heart catheterization.  A left ventriculogram was performed.  The aortic valve was evaluated using catheter pullback technique.

Coronary angiography was performed using an FL4 to inject the left coronary arteries and an AR Mod to inject the right coronary artery.

FFR was estimated using catheter pullback technique from the left main coronary
artery (LMCA) to the aorta.  An FFR wire was not utilized, but calculations were made based upon the mean gradients across the obstructive lesion in the ostium of the LMCA.  

IVUS was performed in the LMCA to evaluate the ostial obstruction.  Significant catheter dampening occurred with engagement of the 6-French Runway CLS3 guiding catheter, so IVUS was performed with the guide disengaged from the LMCA, positioned in the aortic root during IVUS of the ostial LMCA.

Angiography of the right CFA was performed through the sheath.  A 6-French Perclose was utilized to obtain hemostasis of the right CFA percutaneously.

COMPLICATIONS:
None.

ANESTHESIA:
Local with moderate sedation.

HEMODYNAMIC SUMMARY:
The initial aortic pressure measured 167/61 (mean 100).  The LV pressure measured 166/17 with an end diastolic pressure of 32 mmHg.  A subsequent LV pressure measured 157/16 with an end diastolic pressure of 33 mmHg.  There was no aortic valve gradient.  The subsequent aortic pressure measured 157/62 (mean 99).  The rhythm was sinus with heart rates in the 60s.

LEFT VENTRICULOGRAM:
The LV size was normal.  The LV systolic function was mildly reduced globally, ejection fraction 41%.  Mitral insufficiency was moderate to severe with contrast regurgitation into a dilated left atrium and into the left atrial appendage.

DSA OF THE ABDOMINAL AORTA WITH FLUSH RENAL ARTERY ANGIOGRAM,
AND DSA OF THE TERMINAL AORTA WITH ILIAC ARTERY ANGIOGRAM:  
Mild atherosclerotic disease involved the abdominal aorta with a 20% obstructive eccentric lesion just superior to the right renal artery.  Mild atherosclerotic disease involved the infrarenal abdominal aorta, except for the terminal segment, which was 60% obstructed.  The common iliac arteries were previously stented with approximately 30% obstruction within the proximal segments of each stent.

The renal arteries were single with minimal disease bilaterally.

CORONARY ANGIOGRAM:
1.  Coronary artery dominance:  Left.
2.  Left main coronary artery, (LMCA):  60% obstructed in its ostium by calcific disease.  There was significant pressure dampening upon engagement of the left main coronary artery by a 6-French, soft tipped FL4 diagnostic catheter.  Refer to IVUS and hemodynamic assessment of the LMCA, below.
3.  Left anterior descending coronary artery, (LAD): Type 2.  Normal sized,diseased.  There were no significant diagonal branches.
4.  Left circumflex coronary artery, (LCX):  Dominant, normal sized, diseased.  OM1,OM2, and OM3 were normal sized, diseased.  The left PLA was normal sized, diseased.  The left PDA was 50% obstructed by a single lesion.
5.  Right coronary artery, (RCA):  Small, nondominant, 60% obstructed in its ostium with pressure dampening upon engagement with a 6-French AR MOD catheter.  The RCA supplied the right ventricle, with no significant right PDA or PLA.

IVUS AND HEMODYNAMIC ASSESSMENT OF THE LMCA:
A 6-French CLS3 guiding catheter was advanced to the aortic root.  Weight based heparin was administered.  The CLS3 was used to engage the LMCA.  A Runthrough angioplasty guidewire was used to cross the LMCA lesion with the distal segment of the wire advanced into the LAD.  IVUS was then performed on it using a Volcano Eagle Eye Gold IVUS catheter.  Engagement of the LMCA by the guiding catheter resulted in significant pressure dampening.  IVUS was performed with the guide disengaged from
the LMCA, both the image of the ostium of the LMCA, and to avoid prolonged pressure dampening.

IVUS showed significant plaque in the LMCA with a minimum lumen area of 5.0 mm2 in the ostium.

Hemodynamic assessment of the left main coronary artery was done using the soft tipped guiding catheter.  Considering the significance of the ostial LMCA lesion, I did not want to administer adenosine for formal FFR testing.  The pressure gradient was evaluated using catheter pullback technique.

With brief engagement of the guiding catheter in the LMCA, the pressure was ventricularized, with a measured blood pressure of 134/52 (mean 76), with the catheter tip slightly engaging the LMCA.  Catheter pullback from the LMCA to aorta resulted in an aortic pressure of 167/60 (mean of 101).  This corresponded to an estimated fractional flow reserve of 0.75 (mean pressure of 76 divided by a mean pressure of 101).

With catheter engagement in the LMCA for more than 15 seconds, the pressure dampened to 74/38 (mean 51).  The subsequent pullback yielded an immediate aortic pressure of 123/57 (mean 82) and an aortic pressure 15 seconds later of 169/61 (mean 102). 
This calculated to estimated FFR of 0.62 (51 divided by 82) and 0.50(51 divided by 102). During catheter engagement for more than 15 seconds, ischemic ST-T changes were noted, with recovery following disengagement of the catheter.

RIGHT COMMON FEMORAL ARTERY ANGIOGRAM:
The right CFA was normal sized, diseased, and suitable for percutaneous closure.

POST CATH MANAGEMENT:
Refer to post-cardiac catheterization note.


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