# LHC with Bilateral lower extremity runoff



## carelitz (Mar 20, 2018)

I would really appreciate some help with this as I am teaching myself this on the job! 
I came up with:

*93458, 26
75630, 2659*

The other code I was looking at was 75716, 2659...

I am really new to coding this! Thanks for any help and explanations.  


PROCEDURES PERFORMED:
1.  Left heart catheterization.
2.  Coronary angiography.
3.  Left ventriculogram.
4.  Bilateral lower extremity runoff.



INDICATIONS FOR PROCEDURE:  A  patient who presents with a 
non-ST elevation myocardial infarction and also suspected to have severe 
peripheral vascular disease with a poorly healing wound in the right foot.
 He is brought in primarily for invasive risk stratification from the 
cardiac standpoint, but would also consider diagnostic angiography of his 
periphery depending on how the cardiac portion of the study unfolds.

DESCRIPTION OF PROCEDURE:  Informed consent was obtained.  The patient was
brought to the cath lab in a fasting condition.  He was sterilely prepped 
and draped in usual fashion and the left femoral artery was entered using 
modified Seldinger technique.  A 6-French arterial sheath was easily 
established.  Following this, left heart catheterization and coronary 
angiography was done with a 6-French JL 5 and JR4 catheter.  Multiple 
coronary angiograms done in multiple projections.  Following this, a 
6-French pigtail was inserted across the aortic valve and into the left 
ventricle.  Hemodynamic data was gathered.  An LV gram was done in the RAO
projection.  The catheter was pulled back across the aortic valve, where 
no gradient was seen.  At this point, the pigtail was then withdrawn down 
to the level above the aortic bifurcation and a bilateral lower extremity 
runoff was performed.  Following this, all catheters and wires were 
removed and the arterial sheath was removed and hemostasis obtained with 
manual compression.  There were no immediate complications.  The 
intraprocedure medicines include sedatives per nursing flow sheets.  The 
contrast flow and flow amounts elucidated in the cath report.  There was 
35 minutes of sedation time under my direct supervision.

STUDY FINDINGS:
HEMODYNAMICS:  Central aortic pressure was 114/60.  Corresponding LV 
pressure 115/11, pulse A wave of 32.  No gradient across the aortic valve.

ANGIOGRAPHIC FINDINGS:  Left main is a large vessel, has some mild 
irregularity but no significant lesions are seen.  The left circumflex is 
a moderate sized system which has some 25 percent plaquing proximally and 
into the mid vessel.  No high grade lesions are seen.  This system gives 
rise to a small first obtuse marginal branch and then a moderate to large 
second and then smaller terminal marginal branch.  Both of those are free 
of any significant disease.  There is a ramus intermediate vessel present 
which appears to be moderate in caliber and long in length.  This vessel 
has some diffuse tubular stenosis of about 30 percent in the proximal 
portion.  The LAD is a moderate caliber vessel does reach the apex, where 
it ends in a bifurcation.  There is a fairly long segment of disease in 
the proximal vessel on to about 40 percent.  This is also moderate to 
heavily calcified.  There is a diagonal branch, which is moderate in size.
 This has diffuse disease beginning in the ostial portion and then 
actually gets quite tight in the proximal third to about 90 percent 
stenosis.  This is about a 2 mm vessel.  The right coronary artery is a 
dominant vessel.  There is a 95% stenosis in the proximal vessel, followed
by short segment of normal vessel and then a very long diffuse area of 
disease ensues, wherein the vessel appears to be totaled in the distal 
portion.  The very distal portion of this vessel do fill via left-sided 
collateral and appear to consist of a posterior descending and a 
posterolateral branch that are likely at least moderate in size, but do 
not have any obvious focal high-grade abnormalities within themselves.

The left ventriculogram in the RAO projection demonstrates essentially 
inferior akinesis which is near the mid basal inferior segment, severe 
hypokinesis in the inferior apex, moderate hypokinesis of the remaining 
segments.  Overall ejection fraction is reduced and estimated at 
approximately 25-30 percent.  No mitral insufficiency is seen.

In terms of the peripherally anatomy:  The distal aorta has mild 
irregularity. The right common iliac has approximately 30 percent stenosis
in the mid portion.  On the left side, there is less severe disease found 
to be about 20 percent.  The right external iliac has 20 percent disease. 
The left external iliac also has about 20 percent disease.  The internal 
iliac on the right side, did not appear to have any significant disease; 
and on the left side, there may be an ostial narrowing, it is not that 
well visualized.  The right common femoral has a 10 percent plaque.  The 
left common femoral has 20 percent plaque.  The deep femoral on the right 
has 10 percent plaque proximally.  The deep femoral on the left also has 
about 10 percent proximal plaque.  The SFA on the right has in the distal 
portion stenosis of about 60 percent and on the left in this portion the 
stenosis is closer to 80 percent. Also on the right, there appears to be 
significant stenosis in the proximal portion of the popliteal artery and 
on the left only about 25 percent plaque is seen.  On the right side, 
there appears to be a total occlusion of all of the trifurcation vessels. 
He has never really reconstituted 20 degree, on the left side the anterior
tibial is seen somewhat faintly appears to be occluded at least in the mid
portion and the remaining vessels also appear to be occluded.



OVERALL IMPRESSION:
1.  Single vessel plus branch vessel coronary disease.
2.  Severely reduced left ventricular systolic function.
3.  Severe peripheral arterial disease, which is most notable for severe 
disease in the trifurcation vessels.  The trifurcation vessels do not 
appear amenable to revascularization either percutaneously or surgically. 

RECOMMENDATION: For continued medical therapy.  In light of this patient's
coronary artery findings, I would recommend continued medical therapy.  He
has significant anemia and a lot of other medical comorbidities and 
therefore medical management will be pursued.  At least based upon the 
left ventriculogram, there may be nonviable myocardium in the RCA 
distribution.

In terms of peripheral arterial disease, this does not appear 
unfortunately very amenable to revascularization.  Distal vessels, though 
formal vascular surgery consultation is likely pending. Though obviously 
this management decision will be deferred to vascular surgery.


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## Jim Pawloski (Mar 20, 2018)

carelitz said:


> I would really appreciate some help with this as I am teaching myself this on the job!
> I came up with:
> 
> *93458, 26
> ...



I would code 75716 instead of 75630 because both extremities were imaged completely.
HTH,
Jim Pawloski, CIRCC


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## carelitz (Mar 20, 2018)

Thanks so much, Jim! I was really going back and forth with those codes! It was driving me crazy.


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