# Left Heart Cath with 3 Stent Locations



## em2177 (Apr 16, 2012)

NEED SOME ASSISTANCE IN CODING THIS REPORT. THANK YOU!!! 

PREOPERATIVE DIAGNOSIS: Unstable angina, severe.

POSTOPERATIVE DIAGNOSIS:
1. Multivessel coronary artery disease.
2. Multivessel intervention.

PROCEDURE(S) PERFORMED:
1. Left heart catheterization.
2. Coronary angiography.
3. Intraaortic balloon pump.
4. Percutaneous coronary intervention of:
a. Circumflex coronary artery.
b. Left anterior descending artery.
c. Right coronary artery.

PROCEDURE: The patient was prepped and draped in the usual fashion and brought
to the catheterization lab having been premedicated with Xanax and Benadryl.
Using 2% local Xylocaine, the right femoral region was anesthetized. Using the
single-wall technique, the right femoral artery was entered. An introducer
sheath was placed, through which a 4 left Judkins was advanced to the ostium of
the left coronary artery. Several hand injections visualized the artery in
various projections. This catheter was removed and placed with a Williams
right catheter, which was advanced to the ostium of the right coronary artery.
Several hand injections visualized the artery in various projections.
At this juncture, the patient actually became quite unstable and had severe
chest discomfort, 8/10 or 10/10. She was hypotensive with blood pressure 80-90
and tachycardia Because of this, it was elected to place an intraaortic
balloon pump.
The left femoral region was anesthetized. Using the single-wall technique, the
left femoral artery was entered. An introducer sheath was placed, through
which an intraaortic balloon pump was brought just below the left subclavian,
and this was pumped at 1:1 with good expansion of the balloon. At this
juncture, the patient was placed on IV nitroglycerin at 30 meg and was given IV
Lopressor 5 mg q.5 minutes x3. The patient began to stabilize with this with
less discomfort.
Keeping in mind that the patient was on Plavix and quite unstable, it was
elected to try to stabilize this situation as it would be some time before she
would be able to undergo surgery.
At this point, an XB guide was advanced to the ostium of the left coronary
artery. A S'port wire was prepared and a 3-0 balloon. The wire was advanced
down the circumflex, which was quite tortuous and into the distal vessel. The
balloon was advanced over the wire to the point of the lesion and inflated.
This was then removed, and a 3.5 x 24 Promus Element stent was fully inflated
up to 14 atmospheres. Angiograms post showed a markedly improved artery with
no significant residual.
At this juncture, attention was turned toward a high-grade lesion in the I.AD.
The same guide was used. The S'port wire was advanced down the LAD into the
distal vessel. A 2.0 balloon was brought to the point of the lesion and
expanded, and then a 3.0 x 16-mm Promus Element stent was placed across the
lesion and fully inflated. There was still some residual in-stent narrowing,
and therefore a 3.25 balloon was brought in-stent and fully inflated up to 16
atmospheres. Angiograms post showed a markedly improved artery with no
significant residual.
At this juncture, attention was turned toward the right coronary artery. A 4
right Judkins guide was advanced to the ostium of the right coronary artery. A
S'Port wire was placed down the artery, and then a 3.0 x 16 Promus Element
stent was placed across the lesion and fully inflated up to 16 atmospheres.
This was post dilated with a 3.5 x 8 balloon up to 16 atmospheres. Angiograms
post showed a markedly improved artery.
Prior to the procedure, the patient was also given 1 mg of Versed for conscious
sedation.
The patient tolerated the procedure well. There were no complications. The
right femoral sheath was removed, and Angio-Seal was placed. The intraaortic
balloon pump was sewn in place, and the patient returned then to the intensive
care unit in stable condition.

ANGIOGRAPHIC DATA:
1. Severe coronary artery disease: Left main was within normal limits. The
LAD showed a proximal 90-plus-percent lesion. There was a small diagonal
with a high-grade lesion. The circumflex showed a 90-plus-percent lesion,
which looked perhaps at a midsegment between 2 previous stents, and a lesion
after the last stent perhaps representing a geographic miss of the
previously placed stent. The right coronary artery showed an 80% mid
lesion, which appeared to be in-stent restenosis.
2. Intraaortic balloon pump placed.
3. Stenting of 2 lesions in the circumflex with 3.5 x 24 Promus stent.
4. Stenting of a 90% LAD with a 3.0 x 16 Promus Element stent.
5. Stenting of an 80% LAD with a 3.0 x 16 stent, post dilated with a 3.25.
6. Angiograms post of all lesions showed markedly improved arteries.


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## jewlz0879 (Apr 17, 2012)

I see:
92980, LC
92981, LD
92981, 59, RC
33967
93454, 26, 59
414.01

HTH


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## choppe (Apr 29, 2012)

*Similar Situation in Question*

Julie (or anyone else),

I am cleaning up the A/R for a former biller and haven't done cardiology for a LONG time.  I have a similar situation with a very complicated case.  Can you confirm a couple of things for me?

1) Am I right that 33968 (removal of balloon assisted device) is included with 33967 (insertion of balloon assisted device)?
2) Can you bill for separate catheter insertions for different reasons?  When is 93454 billable with a modifier 59?
3) Can you only bill for one stent per artery even if it takes two fix the problem?

Here's a shortened version of the op note in question:

The right femoral artery was cannulated... catheter passed up into the aorta.  We needed to have an aortic angiogram so that we could assess the safety of a prophylactic intraaortic balloon pump... [36200 and 75630 can be billed together, right?]

The left femoral artery was cannulated...an intraaortic balloon pump [33967] was passed into the high descending aorta... Once this was in place, we tried a 6-French guiding catheter through the right femoral artery [93454?] and after injection remained concerned about whether the patient had severe ostial left main coronary disease or not...  We decided to "protect" the left main and circumflex by passing a wire down into the circumflex and another down into the distal LAD.  We used a Maverick balloon and dilated the LAD.  We then did an intravascular ultrasound [92978-LD] throughout the LAD and LM... We, therefore, chose a stent [92980-LD] and deployed it from the distal part of the LAD up through the mid LAD.  We then chose a stent [?] and deployed it so that its proximal part was about 3 or 4 mm from the ostium of the LAD and the distal part extending down into the more distal stent... After stenting the LAD, we removed the circumflex wire because we were not ballooning or stenting the LM.  We then used a balloon [?] to post dilate the distal part of the stent as well as the proximal part of the distal stent.  Then a balloon was used to post dilate throughout the distal 2/3 of the combined length of the two stents...

We then reexamined angiograms and decided to treat a tight stenosis in the posterlateral branch of the left circumflex...we did an intravascular ultrasound of the left circumflex [92979-LC].  We chose a stent and deployed it in the larger of the two posterolateral branches [92981-LC]... the stent was postdilated with a Quantum apex balloon [?] ...intravascular ultrasound was repeated...

An angiogram was performed of the right femoral artery...and Angio-Seal device was deployed.  We then did an angiogram through the left sheath...did not use an Angio-Seal device on it.

Can I bill all of these?  Missing any??
36200-59
75630-26-59
93454-26-59 [Or does this appropriately bundle with the 92980 due to location?]
92980-LD
92981-LC
92978-26-LD
92979-26-LC
33967
33968 [This is not billable when done during the same session, is it?] 

Thanks,

CAH


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