# Lhc/rhc/selective brahiocephalic artery and left subclavian angio/sub clav lima angio



## Jane5711 (Jan 23, 2017)

Hi,
Can anyone help me with this 

PROCEDURES PERFORMED:                                                          
1.  Left heart catheterization.                                                
2.  Selective coronary artery angiography.                                     
3.  Left ventriculography.                                                     
4.  Selective bilateral renal artery angiography.                              
5.  Right heart cardiac catheterization.                                       
6.  Selective right brachiocephalic artery and left subclavian artery          
    angiography.                                                               
7.  Selective left subclavian artery and left internal mammary artery          
    angiography.                                                               

INDICATIONS:                                                                   
1.  Abnormal stress test showing moderate anteroapical ischemia.               
2.  Coronary artery disease, previous history of distal left main coronary     
    stenosis and angioplasty and stent of the obtuse marginal branch of        
    the left circumflex artery.                                                
3.  History of angina.                                                         
4.  Hypertension, hypertensive heart disease, mild mitral regurgitation        
    and mild pulmonary hypertension.                                           
5.  Renal artery atherosclerosis and hypertensive heart disease.               


PROCEDURE:  After the informed consent was obtained, the patient was           
prepped and draped in the usual sterile fashion. Two percent lidocaine was     
used for local anesthesia in the right groin. Vascular access was obtained     
in the right femoral artery and right femoral vein. Over a guidewire, a        
7-French angiographic sheath was placed in the right femoral vein and a        
6-French angiographic sheath was placed in the right femoral artery.           

A 6-French TD Swan-Ganz catheter was introduced through the right femoral      
vein, into the pulmonary artery and right heart cardiac catheterization        
was performed in a routine fashion.                                            

The 6-French pigtail catheter was introduced over a guidewire into the         
left ventricle, left ventricular hemodynamics were measured and left           
ventriculography in the RAO projection was performed. The pigtail catheter     
was removed under hemodynamic monitoring from the left ventricle to the        
aorta.                                                                         

A 6-French JL 3.5 catheter was used to selectively engage the left             
coronary artery and selective left coronary artery angiography was             
performed.                                                                     

A 6-French JL4 catheter was used to selectively engage the right coronary      
artery and selective right coronary artery angiography was performed.          

A 6-French JR4 catheter was then used to selectively engage the right          
brachiocephalic artery and right subclavian artery for angiography to          
visualize the right internal mammary artery and right subclavian artery        
was performed.                                                                 

Then, a 6-French JL4 catheter was used to selecting engage the left            
subclavian artery and was used to obtain the left subclavian artery            
angiography to visualize the left internal mammary artery.                     

Then, a 6-French JR4 catheter was withdrawn over a guidewire to the level      
of the renal arteries.                                                         

A 6-French JL4 catheter was used to selectively engage the left renal          
artery and selective left renal artery angiography was performed.              

A 6-French JR4 catheter was used to selectively engage the right renal         
artery and selective right renal artery angiography was performed.  After      
the diagnostic cardiac catheterization, the guidewire and diagnostic           
catheters were removed. Arterial sheaths and venous sheaths were removed       
and hemostasis was obtained with application of manual pressure and            
hemostatic patch, and the patient was transferred in stable condition to       
the floor for further care with no complications.                              

RESULTS:                                                                       
HEMODYNAMIC DATA:                                                              
1.  Pulmonary capillary wedge pressure is 20/19/14 mm.                         
2.  Pulmonary artery 32/5/20 mm.                                               
3.  Right ventricle 32/6/9 mm.                                                 
4.  Right atrium 13/12/9 mm.                                                   
5.  Left ventricular 159/12/17 mm.                                             
6.  Heart rate 70 beats per minute.                                            
7.  Aortic pressure 154/64/2 mm mean.                                          

OXYGEN SATURATION: Right atrium 74 percent, pulmonary artery 75 percent,       
aorta 100 percent.                                                             

VASCULAR RESISTANCE:                                                           
1.  Pulmonary vascular resistance 162.                                         
2.  Total pulmonary vascular resistance 541.                                   

CARDIAC OUTPUT:                                                                

1.  Cardiac output by Fick method 5.5 liters per minute. Cardiac index is      
    3.18 liters per minute per meter squared.                                  
2.  Cardiac output by thermodilution technique 2.96 liters per minute.         
    Cardiac index is 1.71 liters per minute meter squared.                     

ANATOMIC DATA:                                                                 
LEFT VENTRICULOGRAPHY:                                                         
1.  Anterobasal normal.                                                        
2.  Anterolateral mild-to-moderate hypokinesis.                                
3.  Anteroapical severe hypokinesis.                                           
4.  Distal inferior moderate hypokinesis.                                      
5.  Inferior normal.                                                           
6.  Posterobasal normal.                                                       
7.  Left ventricular ejection fraction is approximately 50 percent by          
    visual estimate with mild gradient across the aortic valve noted, 2        
    plus mitral insufficiency noted.                                           

CORONARY DATA:                                                                 
1.  Heavy calcification noted in the left anterior descending artery, left     
    main coronary artery and left circumflex artery noted                      
    fluoroscopically                                                           
2.  LEFT MAIN CORONARY ARTERY: The left main coronary artery is a moderate     
    caliber vessel. It has a distal 95 percent stenosis. It trifurcates        
    into left anterior descending artery, left circumflex artery and ramus     
    intermedius artery.                                                        



3.  LEFT ANTERIOR DESCENDING ARTERY: The left anterior descending artery       
    has heavy calcification in its proximal portion with an ostial 90          
    percent stenosis as it originates from the distal left main coronary       
    artery. It has a heavily calcified lesion in its proximal portion          
    involving the origin of the 1st and 2nd diagonal branch. The 1st           
    diagonal branch is a small vessel with ostial 90 percent stenosis. The     
    rest of the vessel has mild disease. The 2nd diagonal branch is a          
    small caliber vessel with mild disease. The left anterior descending       
    artery just prior to the origin of the 1st diagonal branch and             
    extending beyond the 2nd diagonal branch has a long calcific 50-70         
    percent stenosis. Distal to the 2nd diagonal branch, the left anterior     
    descending artery has another 30 percent stenosis. Distal to this, the     
    left anterior descending artery is a medium caliber vessel and it has      
    mild disease without any high-grade focal stenosis. The transapical        
    vessel curves around the apex.                                             
4.  LEFT CIRCUMFLEX ARTERY: The left circumflex artery has a calcific 70       
    percent stenosis in its ostial proximal portion followed by moderate       
    disease in its proximal portion with heavy calcification. Mid portion      
    gives rise to a medium caliber 1st obtuse marginal branch which has a      
    widely patent stent in its proximal portion. The mid and distal            
    portion of the posterolateral branch has mild disease with up to 30        
    percent stenosis. Mid AV circumflex artery is a medium caliber vessel      
    with a 30 percent stenosis in its proximal portion, 40 percent             
    stenosis in the midportion, distally continues on as a posterior           
    descending branch, which is a medium caliber vessel with mild disease.     
    Distally, the AV circumflex artery gives rise to 2 small obtuse            
    marginal branches which I lead to 2nd and 3rd obtuse marginal              
    branches. The PDA branch is a small vessel, about 1 mm caliber vessel,     
    without any high-grade focal stenosis.                                     
5.  RAMUS INTERMEDIUS ARTERY:  The ramus intermedium artery is a medium        
    caliber vessel, arises from the left main coronary artery and has mild     
    disease without any high-grade focal stenosis. It also could be            
    calcified possibly at 1st diagonal branch.                                 
6.  RIGHT CORONARY ARTERY:  The right coronary artery is a codominant          
    vessel. The right coronary artery has calcification in its proximal        
    ostial portion with mild disease of the rest of the vessel. Proximal       
    right coronary artery has a 30 percent diffuse stenosis. Mid right         
    coronary is a smaller caliber vessel without any high-grade focal          
    stenosis.                                                                  
7.  BRACHIOCEPHALIC:  The right brachiocephalic artery has no significant      
    disease and divides into the right           subclavian artery and right   
    iliac artery.                                                              
8.  RIGHT INTERNAL MAMMARY:  The right mammary artery is noted to fill         
    through the right subclavian artery           and has no high-grade focal  
    stenosis.                                                                  
9.  LEFT SUBCLAVIAN ARTERY: The left subclavian artery has a 40 percent        
    stenosis in its distal portion and then gives rise to left internal        
    mammary artery. The left internal mammary artery is a medium caliber       
    vessel without any high-grade focal stenosis.                              
10. LEFT RENAL ARTERY: The left renal artery has mild disease in its           
    proximal portion without any high-grade focal stenosis.                    
11. RIGHT RENAL ARTERY: The right renal artery has mild disease in its         
    proximal portion without any high-grade focal stenosis.                    

IMPRESSION:                                                                    
1.  Severe 3-vessel coronary artery disease with 95 percent stenosis of        
    the distal left main coronary artery, 80 percent ostial calcified          
    stenosis of the left anterior descending artery extending into the         
    proximal left anterior descending, 70 percent ostial proximal stenosis     
    of the left circumflex artery with a patent stent in the 1st obtuse        
    marginal branch, 40 percent stenosis of the mid circumflex artery, a       
    codominant vessel; right coronary artery has mild disease, codominant      
    vessel.                                                                    
2.  Mildly decreased left ventricular systolic function with severe distal     
    anteroapical hypokinesis and moderate anterolateral hypokinesis, left      
    ventricular ejection fraction of 50 by visual estimate with 2 plus         
    mitral insufficiency and very mild gradient across the aortic valve.       
3.  Patent right brachiocephalic artery with patent right subclavian and a     
    patent left common carotid artery and patent right internal mammary        
    artery without any high-grade focal stenosis; patent left subclavian       
    artery with a 40 percent stenosis in its distal portion, patent left       
    internal mammary artery without any significant disease.                   
4.  Patent renal arteries bilaterally with mild disease of 30-40 percent       
    stenosis of the right renal artery and mild disease of the left renal      
    artery.                                                                    
5.  Mildly elevated pulmonary artery systolic pressure with normal             
    pulmonary capillary wedge pressure.                                        


RECOMMENDATIONS:                                                               
1.  Recommend urgent treatment with coronary artery bypass graft surgery       
    since there is a 95 percent distal left main coronary artery with          
    heavy calcification extending into the left anterior descending artery     
    and proximal left circumflex artery.                                       
2.  Recommend coronary artery bypass graft surgery for left anterior           
    descending artery, ramus intermedius artery, and the left circumflex       
    artery with 3 bypass grafts.                                               
3.  Right coronary artery may not be grafted.                                  
4.  In the meantime, start the patient on heparin drip.                        
5.  Cardiothoracic Surgery consultation has been obtained.            

I'm not sure if I should code a 93460, 26- 93455,26 or 36215 ???? along with renals


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## jtuominen (Jan 23, 2017)

I go with 93461 and 36252, and 75710-XU as well.

You've got:
- A right heart cath
- A left heart cath/ w LV gram
- coronary angiography
- angiography of LIMA and RIMA for purposes of review for grafting (remember the graft codes indicate "whether native or used for bypass")
These components = 93461

Then you've got:
-- selective right main renal artery angio
-- selective left main renal artery angio
These components = 36252

And Last You've got :
The left subclavian angiogram-- while if this exam was normal I would have considered it a part of roadmapping/guidance to get a good shot of the LIMA.
Being that there was a stenosis found in its distal portion, I think you have cause to bill 75710-XU additionally. But there might be a difference of opinion on that.
IMO I wouldn't bill the catheter placement codes, as that would be an included component of billing 93461 in this scenario.
This component = 75710-XU

Oh and stick -26 where applicable. And don't forget moderate sedation, if applicable


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## Jane5711 (Jan 23, 2017)

*Thank you!!!!*

Thank you!!!!


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## aarias1206 (Mar 25, 2017)

Jane5711 said:


> Hi,
> Can anyone help me with this
> 
> PROCEDURES PERFORMED:
> ...



The proper coding is 93461/26. 36215 selective Cath is not billable when a Cath is already being done. You would be overcoding. 75710 is also included in your Cath code. I did an internal audit with my physicians he was overcoding. This puts a risk for fraud with Medicare.  I contracted an outside audit to confirm my finding and I was correct. I had to send a letter to Medicare send money back on certain cases just like this case you posted. After all the audit was done. Re educated my physicians. The physician thank me. I am the billing manager for his group of 21 Cardiologist. I hope this was helpful to you. Good luck.


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