# Cth and Stent



## nancy.anselmo@ccrheart.com (Mar 12, 2013)

PROCEDURE: Left heart catheterization, selective coronary angiography with
percutaneous intervention of the mid and distal left circumflex and balloon
angioplasty of first marginal with placement of drug-eluting stents.

INDICATIONS: ST-elevation myocardial infarction, VF arrest.

HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old who presented with
decompensated heart failure in the setting of rapid atrial fibrillation. He was
diuresed and cardioverted, developed flash pulmonary edema and was placed in
the ICU. While in the ICU, he developed VT degenerating to VF, received CPR and
shock times three with residual ST-elevation. He was emergently brought to the
cardiac catheterization laboratory. He was back in rapid atrial fibrillation
with tenuous blood pressure.

Informed consent was obtained per his daughter. The patient was placed in the
supine position, radial approach, prepped and draped in the appropriate
fashion. Six French catheter was placed in the right radial artery. A Jacky
catheter was used for selective coronary angiography, left heart
catheterization. At the conclusion of the procedure, a TR band was used for
hemostasis.

FINDINGS:
HEMODYNAMICS: Left ventricular end-diastolic pressure measured 20 mmHg. There
is no transaortic gradient on pullback.

CORONARY ANGIOGRAPHY: Left main coronary artery had mild disease. Left anterior
descending artery had mild disease with an 80% second diagonal stenosis in the
proximal second diagonal. The left circumflex was totally occluded in the mid
circumflex at the takeoff of a prominent marginal that had a 90% ostial
stenosis. The right coronary artery was a large, dominant vessel with extensive
RPDA and PL systems. There was 50% proximal and mid stenosis. There was 70%
distal stenosis. There was a 90% RPDA stenosis and 90 to 80% sequential RPL
stenosis.

Based on the patient's clinical presentation, ST-elevations, it was determined
the total occlusion of the left circumflex was the culprit vessel and this will
be addressed at this setting.

Angiomax was used for effective anticoagulation. EBU 3.75 guide catheter was
used to intubate the left main coronary artery. A run-through wire was placed
distal left circumflex due to the total occlusion. The 2.5 balloon was used to
pre-dilate the lesions. Next, a run-through wire was then redirected to across
the lesion in the first marginal and this, too, was dilated. Next, a 2.25 x 26
Resolute drug-eluting stent was placed in the distal circumflex in an
overlapping fashion. A 2.5 x 18 Resolute was then placed. A Choice PT wire was
then redirected through the previously stented segments into the distal first
marginal of which, a 2.5 balloon was used to dilate the ostium. In a kissing
technique fashion, a 2.5 noncompliant balloon alongside a 2.5 compliant balloon
was then simultaneously dilated at the crux of the marginal and left circumflex
to 10 atmospheres respectively with an excellent angiographic result. There was
TIMI-3 flow in both vessels.

Due to hemodynamic instability with low blood pressures and rapid heart rate
due to atrial fibrillation, it was elected to cardiovert the patient. He was
effectively returned to sinus rhythm which will be dictated in a separate
report.

SUMMARY: Successful percutaneous intervention of the totally occluded left
circumflex and balloon angioplasty of the first marginal with placement of
Resolute drug-eluting stents.

The patient will be loaded on Plavix, maintained on aspirin, Plavix
indefinitely. He will be monitored judiciously. He is currently intubated and
will be followed hemodynamically. Will likely approach his right coronary
artery in a staged fashion. Will focus on medical therapy and maintenance of
rhythm.

We have 
93458-26-59
92928-LC
and this is where we differ
92920-LC
0r 92921-LC
Thanks for your help


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## j.monday7814 (Mar 12, 2013)

first off I think you are undercoding it by using 92928. this case was done for an acute MI with ST elevations and V-Fib, I think that qualifies it for 92941.

As far as the secondary vessel, 92921 is appropriate because the marginal branch is part of the left circumflex system. But if this is a Medicare patient you won't get paid for it. We still report these add-on codes to Medicare in the hopes that they will reverse their decision but its doubtful.


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## nancy.anselmo@ccrheart.com (Mar 12, 2013)

Thank you for your help Nancy


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## rpeterson (Mar 12, 2013)

*cath and stent*

Nancy,

I agree with jeremym@pimaheart.com.  I would code this scenario as 93458-26/59 (diagnostic cath), 92941-LC (culprit lesion during acute MI) and 92921-LC (additional vessel angioplasty because this was performed in the diagonal, which is still part of the circumflex).

Robin Peterson, CPC
University Physicians Inc
QCAE Department


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## nancy.anselmo@ccrheart.com (Mar 12, 2013)

Thanks for your help too, I appreciate it.


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## theresa.dix@tennova.com (Mar 13, 2013)

nancy.anselmo@ccrheart.com said:


> Thanks for your help too, I appreciate it.



Nancy,
 I agree with Jeremy on this. 92941-LC  92921-LC (branch)


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