# Stent coding



## nancy.anselmo@ccrheart.com (May 8, 2013)

The patient is a 60-year-old with severe coronary disease, previous bypass graft, peripheral artery disease, hypertension, diabetes, dyslipidemia presenting with accelerating typical angina pectoris.  He underwent a stress  
test despite medical therapy, which had marked ischemic changes and reproduction of angina.  He is referred for diagnostic angiography.

PROCEDURE:  Informed consent was obtained.  The patient understood the risks, benefits and alternatives of the procedure and agreed to proceed with the procedure.  The right groin was prepped in the usual sterile fashion and 2% lidocaine infused  
subcutaneously until adequate anesthesia was obtained.  Right common femoral artery accessed using modified Seldinger technique of which a 6 French 11 cm sheath was placed without complication.  Diagnostic JL4 and JR4 and IMA catheters were used to  
perform selective coronary angiography and left heart catheterization.  At the conclusion of the procedure, an Angio-Seal device was deployed without complication.

HEMODYNAMICS:  Left ventricular end-diastolic pressure measured 14 mmHg.  There was no transaortic gradient on pullback.

LEFT VENTRICULOGRAPHY:  Deferred.  

CORONARY ANGIOGRAPHY:
LEFT MAIN:  The left main coronary artery had a patent stent seen with mild disease.

LAD:  The left anterior descending artery was totally occluded proximally.  The distal vessel seen being filled from a patent IMA graft.  There was an intervening stenosis in the mid LAD compromising two diagonal branches.  This was about a  90%  
stenosis.  There was also a diffuse stenosis in the midvessel segment more proximally compromising the ostium of the first diagonal as well 80% tubular stenosis.  Both diagonals had compromise of their ostium of about 80% stenosis.  There was mild  
diffuse disease distally.

RAMUS:  There was a ramus intermedius with extensive stenting. There were 2 regions of restenosis, one of which was focal with an 80-90% in the midvessel and one more distally that was an 80% tubular restenosis.  

LEFT CIRCUMFLEX:  Tortuous in its proximal course.  There was a 90% eccentric stenosis.  It gave off a prominent trifurcating marginal system that was subtotally occluded at its ostium.  It is being filled from left-to-left and right-to-left collaterals.

RCA:  Totally occluded proximally.  It was filled by a patent free RIMA graft.  There was diffuse disease throughout distribution in the PL and PDA system.   

GRAFTS:  The vein grafts to the diagonal and marginal were known to be occluded.  The free RIMA to the RCA was patent.  The LIMA to LAD was also patent.

SUMMARY:  This is a patient with 3-vessel coronary disease, high-grade ramus restenosis along with compromise of the diagonal system fed retrograde from patent LIMA as well as a subtotally occluded left circumflex system.

CLINICAL PATHWAY:  Based on the patient's angiographic findings and clinical presentation despite medical therapy and elevated risk stress test, it was decided to proceed with angioplasty.

INTERVENTION:  Angiomax was used for effective anticoagulation.  An EBU 3.75 guide catheter was used to intubate the left main coronary artery.  A Runthrough wire was placed to the distal ramus.  A 2.5 balloon was used to predilate the lesions.  A stent  
was attempted to be passed, however, would not pass through the extensively stented segments.  A buddy wire was then used in order to help guide this process.  A 2.5x26 Resolute was then deployed proximally and postdilated with a 3.0 noncompliant balloon
 to 20 atmospheres.  Next, a 2.5x12 was also applied distally in an overlapping fashion and the stent balloon was used to postdilate the lesion.  TIMI-III flow was achieved with 0% residual stenosis and an effective revascularization of the ramus branch.

Attention was then drawn to the LAD lesion via the IMA.  An IMA guide catheter was used to intubate the internal mammary artery.  A Runthrough wire was then placed in a retrograde fashion across the lesion moving more proximally and the other bypass  
graft and placed into the first diagonal.  A 2.5 balloon was used to predilate the lesion.  A 2.75x14 Resolute was then deployed and postdilated with a 3.0 noncompliant balloon to 18 atmospheres with an excellent angiographic result.  There was no  
residual stenosis at the index lesion.

SUMMARY:  Successful multivessel percutaneous intervention of the ramus intermedius as well as within the native LAD via the bypass graft with placement of Resolute drug-eluting stents.

92937-LD
92929-LD
is this correct Thank you Nancy


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## hjohnson (May 8, 2013)

The 92929-LD is incorrect since it is a different vessel.  Since the Ramus is now a separate vessel from the left coronary anatomy you can code is separately.  I would also code a diagnostic left heart cath with this procedure since it was done prior to the intervention and used to make the decision for the intervention.  These are the codes I would use:

92937-LD
92928-RI
93458-59


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## nancy.anselmo@ccrheart.com (May 8, 2013)

I thank you even my Doc gets confused with the new codes Nancy


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