# Heart Cath and Lima Injection coding Help!!



## Jscsj (Aug 26, 2014)

How would you code the following procedures done on two separate days.  This is all new to me. Thank you!!!

***Day One***
Summary:
Coronary arteries:
Left main: There was a 50 % stenosis in the proximal third of the vessel segment.
Proximal LAD: There was a 100 % stenosis.
1st obtuse marginal' There was a 100 % stenosis at the ostium of the vessel segment.
2nd obtuse marginal: There was a 100 % stenosis at the ostium of the vessel segment.
Ostial RCA: There was a 90 % stenosis.
Proximal RCA: There was a diffuse 100 % stenosis.
Graft to the 1st diagonal: There Is a small vascular territory distal to the lesion.
Graft to the circumflex: The graft was a saphenous vein graft. There was a moderate-sized vascular territory distal to the lesion.
Graft to the RCA: The graft was a saphenous vein graft.

Pre-cath diagnosis: Anginal Mi: unstable angina.
Procedures performed:
Right coronary angiography.
Saphenous vein graft angiography.
Left coronary angiography.
Saphenous vein graft angiography.
Arch aortography.
Impressions/post-cath diagnosis:
1. There is severe diffuse coronary artery disease.
2. The LAD is 100% stenosed in the proximal segment
3. The RCA is 100% stenosed in the proximal segment.
4. The circumflex is diffusely diseased and has a 90% lesion in the mid third of the vessel The first and second marginals are 100% occluded at the ostium
5. There is a vein graft from the aorta which touches down on the first marginal vessel. the second marginal vessel, and
'then the PDA This vein graft is widely patent.
6. There is a vein graft to the first diagonal vessel which is widely patent.
7. The LIMA could not be engaged due to severe stenosis in the ostium of the left subclavian vessel.

Recommendations:
1. Will plan on bringing the patient back tomorrow for a left subclavian angiogram and LIMA Injection since we could not
engage those vessels today.
2. Will use a left radial approach to access those arteries.
3. Further management decisions to be determined following the LIMA injection.
Coronary arteries: Left main: There was a 50 % stenosis in the proximal third of the vessel segment. Proximal LAD'
There was a 100 % stenosis. 1st obtuse marginal: There was a 100 % stenosis at the ostium of the vessel segment. 2nd
obtuse margin"" There was a 100 % stenosis at the ostium of the vessel segment Ostial RCA: There was a 90 %
stenosis. Proximal RCA: There was a diffuse 100 % stenosis. Graft to the 1st diagonal: There was a small vascular
territory distal to the lesion. Graft to the circumflex: The graft was a saphenous vein graft. There was a moderate-sized
vascular territory distal to the lesion. Graft to the RCA' The graft was a saphenous vein graft .

Procedure:
1. Right femoral artery access The puncture site was infiltrated with local anesthetic. The vessel was accessed using the modified Seldinger technique, a wire was threaded into the vessel, and a sheath was advanced over the wire
into the vessel.
2. Right coronary artery angiography. A catheter was advanced to the aorta and positioned in the vessel ostium under fluoroscopic guidance. Angiography was performed in multiple projections using hand-injection of contrast
3. Saphenous vein graft angiography. A catheter was advanced to the aorta and positioned at the aortic anastomosis of the graft under fluoroscopic guidance. Angiography was performed in multiple projections using hand-injection of contrast.
4. Left coronary artery angiography. A catheter was advanced to the aorta and positioned in the vessel ostium under fluoroscopic guidance. Angiography was performed in multiple projections using hand-injection of contrast.
5. Saphenous vein graft angiography. A catheter was advanced to the aorta and positioned at the aortic anastomosis of the graft under fluoroscopic guidance. Angiography was performed in multiple projections using hand-Injection of contrast.
6. Arch aortography. A catheter was placed and contrast was injected.
Medications given: Midazolam, 1 mg, IV, at 10:40. Fentanyl, 25 meg, IV, at 10:43.
Procedure completion: Radiation exposure: Fluoroscopy time: 11.25 min.
Contrast given: Omnipaque 110 ml.

Complications:
1. No complications occurred during the cath tab visit
2. Minimal Blood Loss occurred during the cath lab visit.
3. Specimen: NONE occurred during the cath lab visit

Hemodynamic tables
Hemo Pressures Baseline
HR 60
Aortic Pressure (S/D/M) 168/65/102
HEMO CALCULATIONS Baseline
HR 60

***Day Two***
Summary:
Coronary arteries:
Graft to the LAD: The graft was a LIMA There was a moderate-sized vascular territory distal to the lesion.
Pre-cath diagnosis: Angina/MI: unstable angina.
Impressions/post-cath diagnosis:
1. This was a limited angiogram of the left subclavian artery from its origin and the LIMA.
2. The LIMA is patent and feeds a patent LAD.
3. There is a moderate to severe stenosis of the ostium of the subclavian artery.
Recommendations:
1. Consultation with vascular surgery regarding possible interventions to the ostium of the subclavian vs continued surveillance and medical therapy.
Coronary arteries: Graft to the LAD: The graft was a LIMA. There was a moderate-sized vascular territory distal to the
lesion. Bypass graft(s) patent.

Hemo Pressures Baseline
HR 55
Aortic Pressure (S/D/M) 150/65/95


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## jewlz0879 (Sep 3, 2014)

93455-26 includes catheter placement(S) in bypass grafts (left internal mammary, free arterial, venous grafts) which he met by accessing the LIMA and SV grafts. 

I see coronary angio's and the grafts, I do not see where the cath crossed the aortic valve for a LV gram or LVEDP. 

If that were present, then you could capture 93459-26. 

Have a great day!


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