# heart cath & additional arterial access



## maryann1224@bellsouth.net (Sep 19, 2012)

was wondering if left heart cath and additional arterial access is billable as 93458(26) and 36120 , dr clearly documented reason for additional access, would a modifier be needed also? thanks so much for your help!! i pasted portion of report below:



1. Left heart catheterization
2.  Left ventriculogram.
3.  Coronary angiography.
4.  Additional arterial access.



CLINICAL HISTORY:
The patient is a 78-year-old male with episodic chest discomfort
underwent stress testing demonstrating moderate inferior perfusion
defect.  Initially cardiac catheterization was attempted from a
radial approach.  However, due to spasm in the radial artery were
unable to pass the catheter above the elbow and had to abandon the
radial approach for a femoral approach.

PROCEDURE IN DETAIL:
After obtaining informed consent, the patient was transported to
the cardiac catheterization suite where he was he was prepped and
draped in a sterile fashion.  Lidocaine 2% was used to infiltrate
the skin and subcutaneous tissue overlying the right radial
artery.  Percutaneous access was obtained utilizing the Seldinger
technique and a micropuncture kit with placement of a #5 French
sheath.  An Allen's test had been performed demonstrating adequate
collateral circulation.  We advanced a J-wire into the radial
artery but met resistance likely due to redundancy of the radial
artery.  I therefore exchanged the J-wire for Wholey wire.  With
the Wholey wire I was easily able to advance the wire into the
subclavian artery, however, upon advancing my catheter over the
wire there was significant resistance at the level of the elbow.
This was likely secondary to redundancy of the radial artery or
radial loop that had been straightened by the wire.  At this time
we abandoned this approach and percutaneous access was then
obtained in the right common femoral artery utilizing the
Seldinger technique and a 6-French sheath was placed.  I used a
6-French pigtail catheter across aortic valve and perform RAO
ventriculogram.  I used a JL-4 for left coronary angiography and a
JR-4 for right coronary angiography.  A StarClose was deployed in
the right common femoral artery with adequate achievement ........


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## Jim Pawloski (Sep 20, 2012)

maryann1224@bellsouth.net said:


> was wondering if left heart cath and additional arterial access is billable as 93458(26) and 36120 , dr clearly documented reason for additional access, would a modifier be needed also? thanks so much for your help!! i pasted portion of report below:
> 
> 
> 
> ...



I would bill for the second access, since it was tried but not able to be used.  Would be the same as the vessel was occluded.
HTH,
Jim Pawloski, CIRCC


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## dpeoples (Sep 20, 2012)

Jim Pawloski said:


> I would bill for the second access, since it was tried but not able to be used.  Would be the same as the vessel was occluded.
> HTH,
> Jim Pawloski, CIRCC



I agree with Jim.


HTH


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## maryann1224@bellsouth.net (Sep 20, 2012)

would the 59 modifier be appropriate; or 52 ? 

thank you!


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## dpeoples (Sep 20, 2012)

maryann1224@bellsouth.net said:


> would the 59 modifier be appropriate; or 52 ?
> 
> thank you!




I would use modifier 59.

HTH


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## margsablan (Sep 24, 2012)

Listed below are the guidelines.
Services considered included in cardiac catheterization/angiography procedures (93452-93461) are as follows, when indicated:
a. Local anesthesia and/or sedation
b. Introduction, positioning, and repositioning of catheters
c. Recording of intracardiac and intravascular pressures
d. Obtaining blood samples for blood gases
e. Cardiac output measurements
f. Monitoring services, e.g., ECCS, arterial pressures, oxygen saturation
g. Vascular catheter and line removal
h. Final Evaluation
i. Written Report

Code 93452-93461 stated that introduction, position and repositining of catheters are included.  Also,  I read the op report stated that left heart and right heart angiography.  You may want to read the definition of modifiew 53, 73 and 74.  It may apply for discontinued procedure.  If the introduction is bundle to the code, I am not sure if you can bill for the discontinued intro from branchial to fermoral.  You may consider modifier 22 For unusual procedure.  When the work required to provide a service is substantially greater than typically required.  This include: increase intensity , time, techincal difficulty of procedure, severity of patient's condition, physical and metal effort required.  It has to be documented.  Affixed to the catherization you will reumbursed more.

It is getting to long.  Hopefully this will help


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## maryann1224@bellsouth.net (Sep 24, 2012)

thank  you!


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