# Need some help coding this.....



## jlb102780 (Oct 29, 2009)

Here's what I got from the report (which is very long, so thank you to everyone that reads it  )any suggestions or additional comments would be wonderful 

92980-LC
33970
33971
33210
71090-26
93510-26
93545
93556-2659
93543
93555-2659
93540

NAME OF TEST:                                                                 
   1. Left heart cardiac catheterization.                                     
   2. Coronary angiography.                                                   
   3. Left ventriculography.                                                  
   4. Saphenous vein bypass graft injection.                                  
   5. Rotational atherectomy with subsequent implantation of four overlapping 
       Promus drug-eluding intracoronary stents into the very proximal aspect 
       of the left circumflex coronary artery, including its ostium all the   
       way down into the distal left circumflex coronary artery.              
   6. Insertion of an intraaortic balloon pump via the left femoral artery.   
   7. Insertion of a transvenous temporary pacemaker via the left femoral     
       vein.                                                                  

HISTORY                                                                       
The patient is a very pleasant, 62-year-old female with a history of known    
atherosclerotic coronary artery disease.  She actually underwent coronary     
artery bypass surgery back several years ago.  She had two bypass grafts      
placed at that time.  She had a single bypass graft off her aorta which       
bifurcated and one limb went to her left anterior descending and second limb  
went to the obtuse marginal branch of the left circumflex coronary artery.    
At the time of her previous cardiac catheterization two years ago, she was    
noted to have the limb to the obtuse marginal branch to be totally occluded.  
The graft to the left anterior descending was patent.  She has a nondominant  
right coronary artery.  The patient presented to Baptist Medical Center with  
some GI type symptoms.  She subsequently developed an episode of severe chest 
pain after being in the hospital and was noted to have transient ST segment   
elevation in leads 1 and AVL along with marked reciprocal ST segment          
depression in her anterior precordial leads as well as in her inferior leads. 
After stabilization, she was brought to the cardiac catheterization           
laboratory for further evaluation today.                                      

PROCEDURE                                                                     
The patient was brought to the cardiac catheterization laboratory in very     
stable condition.  The right groin area was prepped and draped in the usual   
sterile fashion.  Using 1% Xylocaine, the right femoral area was              
anesthetized.  Using a Cook needle, the right femoral artery was easily       
entered without any difficulty and a 6 French sheath was placed via the       
Seldinger technique.  This sheath was aspirated and flushed.  Diagnostic      
coronary angiography was then performed utilizing a 6 French 4 left Judkins 5 
French 4 left Judkins catheters in order to inject the patient's left         
coronary artery.   It should be noted that the patient had marked dampening   
of pressure when both catheters were inserted.  The right coronary artery was 
injected non-selectively with a 4 French 4 Williams right coronary diagnostic 
catheter.  The patient was noted to have a small, nondominant right coronary  
artery which supplies very little myocardium from a previous cardiac          
catheterization.  Utilizing the same 5 French Williams right coronary         
diagnostic catheter, we were able to manipulate the catheter into the bypass  
graft to the left anterior descending.  This saphenous vein bypass graft to   
the left anterior descending was injected.                                    

We then performed a left ventriculogram in the 30 degree RAO projection       
utilizing a 6 French angled pigtail catheter.  This angled pigtail catheter   
was then pulled back across the aortic valve in order to measure any possible 
transaortic valve gradient.  Upon reviewing the patient's cineangiograms, it  
was very obvious that the patient had rather pronounced left ventricular      
systolic dysfunction.  Her left ventricle appeared to have an ejection        
fraction of approximately 25%.  This was clearly worse than it had been on    
previous cardiac catheterization a couple of years ago.  She had a patent     
bypass graft to the left anterior descending.  Her right coronary artery, as  
mentioned earlier, was a small vessel which was nondominant.  The patient had 
severe disease in her proximal left circumflex coronary artery with an 80%    
calcified lesion in the ostial part of the circumflex at its takeoff from the 
left main.  In the proximal circumflex, further downstream, there was a 70%   
narrowing noted.  In the mid left circumflex coronary artery, there was a 60% 
narrowing noted.  In the distal left circumflex coronary artery prior to a    
couple of distal obtuse marginal branches and a posterior descending branch,  
there is a 60% lesion noted.                                                  

After careful review of the patient's cineangiograms, I felt that the best    
course of action would be to perform a rotational atherectomy on this very    
proximal circumflex which appeared angiographically to be heavily calcified.  
I felt this would give the best chance for getting stents to go further down  
the proximal and possibly into the mid left circumflex coronary artery.  I    
felt we should try balloon angioplasty first and see how that went and then   
probably plan to switch to a rotoblater.  I also felt that the patient had    
severe left ventricular systolic dysfunction and also had rather significant  
damping of pressure measured with the catheter tip with just diagnostic       
catheters for the cardiac catheterization.  I therefore felt that we should   
use a side hole guide for the intervention and also should place intraaortic  
balloon pump.  I also felt that we should place a venous sheath in case the   
patient needed to have a pacing catheter placed for the rotational            
atherectomy part of the procedure.                                            

We therefore turned our attention to the patient's left groin area.  The left 
femoral area was anesthetized carefully.  Using a Cook needle, the left       
femoral vein and left femoral artery were easily entered without any          
difficulty and a 6 French sheath was placed in the left femoral vein and a 6  
French sheath was placed in the left femoral artery.  Both sheaths were       
aspirated and flushed.  I then switched out for a 7.5 French balloon pump     
sheath in the patient's left femoral artery.  We then advanced a 7.5 French   
intraaortic balloon catheter through the left femoral artery up into the      
patient's aorta without difficulty.  The balloon pump catheter was carefully  
aspirated and flushed.  It was connected up to the balloon pump console and   
excellent diastolic augmentation was obtained.                                

The patient was then given 5000 units of intravenous heparin.  We             
subsequently placed a 5 French pacing catheter out into the patient's right   
ventricle as well. Adequate pacing thresholds were obtained.  The pacemaker   
was set in the VVI mode with backup ventricular pacing at a rate of           
approximately 50 beats per minute.  It should be noted that during the        
rotational atherectomy, the patient did require transvenous pacing.           

I then placed a 6 French 4 left Judkins angioplasty guiding catheter with     
side holes up into the ostium of the patient's left main coronary artery.     
There was no damping of pressure measured at the catheter tip since there     
were side holes present.  I then manipulated a 0.014 inch high-torque Floppy  
angioplasty  wire down past the lesion out into the patient's proximal to mid 
left circumflex coronary artery.  A couple of balloon inflations were made to 
6 atmospheres of pressure and subsequently to 4 and 5 atmospheres of          
pressure.  There appeared to be significant waist present on the balloon.  I  
felt that on the balloon would be insufficient.  We therefore removed the     
balloon catheter.  We switched out for a 2 mm Maverick angioplasty balloon    
catheter, the balloon being 9 mm in length.  This balloon catheter was        
advanced down over the angioplasty wire out into the distal circumflex.  We   
subsequently manipulated the angioplasty wire down out into the proximal      
aspect of the PDA.  The balloon catheter was brought down into the PDA.  We   
subsequently switched out for a 0.009 inch Floppy rotational atherectomy      
wire.  This roto-wire was placed out into the posterior descending branch of  
the left circumflex coronary artery distally.  I then removed the balloon     
catheter.  We selected a 1.5 mm rotational atherectomy burr.  This burr was   
brought down and tested outside the body at 164,000 RPMs.  The rotational     
atherectomy burr was then brought down into position in the patient's left    
main coronary artery.  Prior to every burr run, the patient received          
intracoronary injection of 200 micrograms of Verapamil.  A total of 10 burr   
runs were then performed.  We were able to successfully perform rotational    
atherectomy on the very proximal left circumflex coronary artery at its       
ostium extending into the proximal circumflex.  The rotational atherectomy    
burr was removed.  The guiding catheter, however, had softened somewhat.  I   
felt that we needed to place a new guiding catheter.  We removed the entire   
angioplasty system and switched out for a 6 French 3.5 Voda angioplasty       
guiding catheter with side holes.  This guiding catheter was inserted into    
the ostium of the patient's left main coronary artery.  I then manipulated a  
0.014 inch high-torque Floppy angioplasty wire down past the lesion out into  
the distal aspect of the patient's left circumflex coronary artery.  When I   
was satisfied with the position of the angioplasty wire, we then were able to 
bring down a 2.5 mm Maverick angioplasty balloon catheter down into the mid   
left circumflex coronary artery.  A balloon inflation was made to 9           
atmospheres of pressure and held for 24 seconds.  I then removed the balloon  
catheter.  I then selected a 2.75 mm Promus drug-eluding stent catheter with  
the stent being 15 mm in length.  Prior to doing that, while the balloon      
catheter was still down, we switched out for a 0.014 inch Grand Slam          
angioplasty exchange wire.  This wire is somewhat stiffer and I felt it would 
allow better support for placing stents.  I then was able to surprisingly     
bring the Promus stent catheter down all the way through the proximal         
circumflex and all the way down out into the distal circumflex.  I felt that  
we should stent the most distal lesion since we were able to bring a stent    
catheter down this far.  The stent catheter was advanced out into the distal  
left circumflex coronary artery prior to its bifurcation.  When I was         
satisfied with the position of the stent catheter, I inflated the stent       
catheter very carefully to 9 atmospheres of pressure and held this balloon    
inflation for 24 seconds.  The stent catheter was then removed.  I then       
selected another 2.75 mm Promus drug-eluding stent catheter, the stent being  
18 mm in length.  This stent catheter was then brought down into position in  
such a way that it overlapped distally with the proximal aspect of the        
previously deployed stent.  This stent catheter was placed in position and    
was then inflated for 11 atmospheres of pressure and was held for 45 seconds  
in order to deploy the stent.  We then removed the stent catheter.  I then    
selected another 2.75 mm Promus drug-eluding stent catheter with the catheter 
being 23 mm in length.  This stent catheter was again placed in such a        
fashion that it overlapped the proximal aspect of the previously deployed     
stent.  There were essentially overlapping stents from distal to proximal     
during this time.  When I was satisfied with the position of this stent       
catheter, we inflated the catheter to 11 atmospheres of pressure and held     
this balloon inflation for 45 seconds as well.                                

We then deflated the stent catheter and removed it.  Serial cineangiograms    
really made the proximal and mid to distal left circumflex coronary artery to 
look quite good.  I selected a 2.75 mm NC Voyager RX angioplasty balloon      
catheter.  A total of three balloon inflations were made within the           
overlapping stented segment in the proximal to distal left circumflex         
coronary artery.  The first balloon inflation distally was 18 atmospheres of  
pressure and the next subsequent two inflations were to 22 atmospheres of     
pressure.  Each balloon inflation was held for approximately 35 seconds.  We  
then deflated the NC Voyager high pressure angioplasty balloon catheter and   
removed it.  I then selected a 3 mm Promus drug-eluding stent catheter, with  
the stent being 23 mm in length.  This stent catheter was placed in such a    
way that the distal aspect of this new stent overlapped with the proximal     
aspect of the most recently deployed stent distally.  The proximal aspect of  
this new stent was placed at the ostium of the left circumflex coronary       
artery at its takeoff.  When I was satisfied with the position of the stent   
catheter, we inflated the stent catheter very carefully to 13 atmospheres of  
pressure and held this balloon inflation for 30 seconds.  There was some      
waist noted in the very proximal aspect of the stent at the ostium at its     
takeoff from the left circumflex coronary artery from the left main coronary  
artery.  We subsequently selected a 3 mm NC Merlin high pressure angioplasty  
balloon catheter, the balloon being 20 mm in length.  Two balloon inflations  
were made within the stented segment proximally.  Each balloon inflation was  
to 18 atmospheres of pressure and was held for 22 seconds.  I then selected a 
3 mm Quantum Maverick high pressure angioplasty balloon catheter, the balloon 
being 12 mm in length.  A high pressure balloon inflation was made in the     
very proximal aspect of the stented segment to 20 atmospheres of pressure and 
was held for 40 seconds.  We then deflated the Quantum Maverick high pressure 
angioplasty balloon catheter and removed it.  Subsequent cineangiograms       
revealed a very nice angiographic result.  The stent was widely patent.       
There was excellent flow in the distal vessel.  There was slight narrowing    
noted at the takeoff of the left circumflex coronary artery at its ostium.    
This was relatively mild in the 10 to 20% range.  The entire overlapping      
stented segment, however, appeared widely patent and there was excellent flow 
in the distal circumflex.  The angioplasty system was then removed.  The      
pacemaker catheter was removed.  The patient was taken upstairs in very       
stable condition.  She was free of chest pain at the conclusion of the        
procedure and was hemodynamically stable.  Her balloon pump was at 1 to 1     
during the case and was cut down to 1 to 2 when she left the cath lab.  It    
will be pulled later on today.                                                

RESULTS                                                                       

ANGIOGRAPHY                                                                   
   1. The left main coronary artery is normal.                                
   2. The left anterior descending coronary artery is totally occluded after  
       the takeoff of the first septal and first diagonal branches.  The      
       first septal branch is fairly large in size and it has mild plaquing   
       noted throughout.  The first diagonal branch is moderate in size and   
       has some mild disease present in its proximal aspect.  This vessel,    
       however, is too small for any type of catheter based intervention.     
   3. The left circumflex coronary artery is a large and dominant vessel.  In 
       the very proximal circumflex, shortly after its takeoff at its ostium, 
       there was a calcified complex 90% lesion noted.  Further down in the   
       proximal mid left circumflex coronary artery, there is a subsequent    
       80% narrowing noted.  In the mid left circumflex coronary artery more  
       distally, there is a 60 to 70% lesion noted.  At the distal circumflex 
       prior to the takeoff of the distal obtuse marginal branches and        
       posterior descending branch, there is a 60% lesion noted.              
   4. The right coronary artery is a very small vessel which supplies very    
       little myocardium.                                                     
   5. The saphenous vein bypass graft to the left anterior descending is      
       patent with good runoff.  The left anterior descending is a relatively 
       small vessel distally, however.                                        
   6. The saphenous vein bypass graft to the obtuse marginal branch of the    
       left circumflex coronary artery is known to be totally occluded.  It   
       was not selectively injected.                                          
   7. A left ventriculogram reveals severe global hypokinesis.  The overall   
       left ventricular ejection fraction was estimated to be approximately   
       25%.  The left ventricle appears mildly dilated.  There is very        
       minimal mitral regurgitation detected.                                 
   8. After successful rotational atherectomy with subsequent implantation of 
       four overlapping Promus drug-eluding stents into the very proximal     
       left circumflex coronary artery at its ostium and extending down       
       through the proximal circumflex out into the mid and subsequently the  
       distal left circumflex coronary artery, the long area of severe        
       disease with several 60 to 90% lesions preintervention was reduced to  
       no residual narrowing postintervention.  There was excellent flow in   
       the distal vessel.  There was no evidence of dissection.               

CONCLUSIONS                                                                   
   1. Severely depressed global left ventricular systolic function as         
       described above.                                                       
   2. Normal left main coronary artery.                                       
   3. Totally occluded left anterior descending coronary artery after the     
       first septal and first diagonal branch.                                
   4. Large and dominant left circumflex coronary artery which has a severe,  
       high grade, complex, calcified lesion present in the very proximal     
       aspect at its ostium at its takeoff from the left main coronary        
       artery.  There was also severe obstructive narrowing noted in the      
       proximal mid and even distal left circumflex coronary artery prior to  
       severe distal obtuse marginal branches as well as a posterior          
       descending branch.                                                     
   5. Very small and nondominant right coronary artery which supplies very    
       little myocardium.                                                     
   6. Widely patent saphenous vein bypass graft to the left anterior          
       descending with the left anterior descending distally being a          
       relatively small vessel.                                               
   7. Successful rotational atherectomy of the very proximal left circumflex  
       coronary artery with subsequent implantation of four overlapping       
       Promus drug-eluding stents into the ostium of the left circumflex      
       coronary artery extending throughout the proximal circumflex down into 
       the mid and subsequently the distal left circumflex coronary artery.   
       The proximal stent is a 3 mm Promus drug-eluding stent which is 23 mm  
       in length.  The three distal stents are all 2.75 mm Promus             
       drug-eluding stents which are 23 mm, 18 mm, and 15 mm in length,       
       respectively.  The severely diseased and heavily calcified proximal    
       left circumflex coronary artery with several severe lesions in the mid 
       and distal left circumflex coronary artery preintervention was reduced 
       to less than 10 to 20% residual narrowing in the very ostial part of   
       the circumflex with no residual narrowing noted throughout the rest of 
       the left circumflex coronary artery.  There was no evidence of         
       dissection and there was excellent flow in the distal vessel.          
   8. Successful implantation of the intraaortic balloon pump via the right   
       femoral artery for the interventional procedure.                       
   9. Successful insertion of a transvenous temporary ventricular pacemaker   
       from the left femoral vein.


----------



## deedeefronius (Oct 29, 2009)

This is the very reason I don't want to do cardiology!!!  You are the bomb!  I wish I could be of any sort of help, you I'm frazzled!!!


----------



## dpeoples (Oct 29, 2009)

jlb102780 said:


> Here's what I got from the report (which is very long, so thank you to everyone that reads it  )any suggestions or additional comments would be wonderful
> 
> 92980-LD
> 33970
> ...



wow, that is a long report...here goes:
92980 LC for the stents
93510 for the LHC
33967 IABP
33210-59 Temp Pacer
93540 Injection of Venous Graft
93545 Injection of Coronary arteries
93543 Injection of LT Ventrical
93555 26,59 Supervision/Interpretation of Lt Ventriculography
93556 26,59 S & I of Coronary Arteries

I would not charge for the removal of the IABP or Temp Pacer, nor the Atherectomy and Angioplasty of the LC (included with stent placement).
I think that is everything...
HTH


----------



## sowmya (Nov 2, 2009)

jlb102780 said:


> Here's what I got from the report (which is very long, so thank you to everyone that reads it  )any suggestions or additional comments would be wonderful
> 
> 92980-LC
> 33970
> ...



The way you coded seems to be perfect except that I don't see a code for implantation of the intraaortic ballon pump . Is it inclusive of the angio stent code. I am not sure. Please check on that one. I don't have any of my literature handy now to check on it. In case if you get to know about it let me know. Otherwise everything is good. Also I only wish I get such a descriptive op reports for me to code . Good luck.
skk


----------



## mannlx (Nov 6, 2009)

dpeoples has coded this report correctly, I was in cardiology but am now in pathology but that is not that uncommon of a report and the coding dpeoples gave was exactly what I would use. No codes for removals.

lisa


----------

