# Subclavian arteriogram



## OPENSHAW (Nov 7, 2012)

Need help coding this op report, please.

Operations performed:

1)  selective coronary angiography.
2)  left heart catheterization.
3)  lv angiography.
4)  ascending aortography.
5)  nonselective left im angiography.

Postoperative diagnosis:    Angina pectoris, s/p avr, concentric lvh, and s/p pci.

*are the diagnosis codes:  413.9, v43.3, 429.3, and v45.82.*

description of the procedure:

After the risks were explained to the patient and proper consent was signed, the patient was brought to the catheterization laboratory where he was prepped and draped in the usual manner in sterile fashion.  Arterial access was gained via the modified seldinger technique in the right common femoral artery.  Following this, j-tip guidewire was inserted into the aorta and a jl4 diagnostic catheter was advanced over the wire into the left main system.  The wire was removed and catheter was aspirated and flushed in the usual manner.  Unfortunately, the jl4 was unable to sit into the left coronary system and ultimately the jl5 diagnostic catheter was successful on seeing the left coronary system.
Pictures were taken of the left coronary system at that time and the jl5 was removed over the guidewire and replaced with a jl4 diagnostic catheter.  Wire was then removed.  The catheter was aspirated and flushed in the usual fashion and the right coronary artery ostia was engaged and pictures were taken of the right system.  Following this, the prior saphenous vein graft ostium was engaged and pictures were taken of this occluded graft.  Angiography of the ima was then undertaken.  The left subclavian was cannulated via the jr4 diagnostic catheter.  However, unfortunately, a j-tipped wire and wholey wire were unable to be passed into the distal subclavian as the proximal vessel was extremely tortuous and the branch of the vertebral came off in such a manner as to have the wire selectively engaged vertebral preferentially.  An ima diagnostic and jr catheters were attempted as well as a wholey wire and j-wire were attempted without success.  Some 30 minutes were spent attempting to pass this wire without any successful complication.  After this was decided, then nonselective ima shot was the next best course of action and subsequently nonselective left ima shots were undertaken.  Following this, the jr4 was removed over the wire and replaced with a pigtail catheter, which crossed the aortic valve into the left ventricle at which time pressures were measured and left ventriculography was performed.  Following this, the pigtail was pulled back across the aortic valve.  No gradients were observed.  Following this, an ascending aortogram was obtained to ensure that there were no other grafts that were patent that we had missed.  Following this, the pigtail catheter was removed over the wire.  Right femoral angiography was undertaken, at which time, the patient felt a suitable candidate for closure device.  Subsequently, a #6- french mynx closure device was administered without complication and with excellent hemostasis.  The patient was subsequently discharged to the holding area in excelllent condition. 

Findings:  The left main coronary did not have any significant disease.  There was mild plaquing.  Left circumflex was a large vessel.  Giving off distal om branches with no significant disease.  The lad was occluded just after the first diagonal, which was a large vessel.  The first diagonal had a stent placed proximally at the ostium, which showed minimal in-stent restenosis for approximately 30%.  The diagonal was otherwise open with mild distal disease.  Right coronary artery was occluded proximally which was known.  An svg graft was occluded 100% proximally which was known.  The lima was patent and extended down to the mild lad, which filled the entire lad and the distal diagonal, which did have distal disease, but no significant stenosis.  The distal lad did fill the pda and some of the right coronary artery via left to right collaterals.
Overall, there were no significant changes from the prior catheterization.  The stent placed at the diagonal remained patent.  Left ventriculography revealed normal wall motion with ejection fraction of 60%.

Would the cpt codes be the following:

93459-26 
75685-26-59
36216-59

i would not code 75600-26 (thoracic aortogram) and 75710-26 (femoral angiography) due to these codes bundle and are not separate billable procedures based on this op report.

I would bill:                      93459-26,          dx. Is 413.9, 429.3, v43.3, v45.82
                                           75685-26-59      dx. Is 413.9, 429.3, v43.3, v45.82
                                           36216-59           dx. Is 413.9, 429.3, v43.3, v45.82

would this be correct?  Thank you!!!!!!!


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## Jim Pawloski (Nov 7, 2012)

OPENSHAW said:


> Need help coding this op report, please.
> 
> Operations performed:
> 
> ...



For the procedure, you have only 93459-26.  You don't have to be selective in the LIMA to be able to bill for the grafts.  Can anyone else help with the dx. codes?
HTH,
Jim Pawloski, CIRCC


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## OPENSHAW (Nov 13, 2012)

Jim Pawloski said:


> For the procedure, you have only 93459-26.  You don't have to be selective in the LIMA to be able to bill for the grafts.  Can anyone else help with the dx. codes?
> HTH,
> Jim Pawloski, CIRCC


Jim,
     Noone else has responded.  Thank you for responding.  Regarding the CPT Codes, I should only bill code 93459-26, what about the other cpt codes?  Thanks for your help!!!!

Would the cpt codes be the following:

93459-26 
75685-26-59
36216-59

i would not code 75600-26 (thoracic aortogram) and 75710-26 (femoral angiography) due to these codes bundle and are not separate billable procedures based on this op report.????


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