# LHC with coronary anomaly



## Cyndi113 (Sep 17, 2009)

Good morning, 

I'm very new to cath coding and need help deciding if this heart cath may actually be billed as an LHC or a CTA. Please HELP! 

INDICATION FOR PROCEDURE:
Recurrent chest pain consistent with angina pectoris in a patient with
multiple risks for coronary artery disease.

TECHNIQUE:
After informed consent was obtained from patient, patient was brought to the
cardiac catheterization laboratory in a fasting nonsedated state. He was
prepped and draped in sterile manner for the above procedures. Versed and
fentanyl were used for conscious sedation. 2% Xylocaine was used for
local anesthesia of the right groin.
Thereafter, a 6-French sheath was placed in the right femoral artery by
modified Seldinger technique. A 6-French JL4 catheter was used to
attempt to engage the left main coronary artery; however, with this
catheter no evidence of a left main could be found. A 6-French
multipurpose B2 catheter was then exchanged over a wire. It was found
that the patient's coronary system is congenitally anomalous. There is a
common origin for the right coronary artery as well as the left main
coronary artery. Multiple views of the paient's entire coronary system
were taken by using th B2 catheter to selectively engage his singular
coronary ostium. When this was complete the same catheter was used to
perform the left ventriculogram. The procedure was tolerated well. At
the conclusion of the procedure, groin hemostasis was achieved with
direct manual compression.

Results:
hemodynamics, no significant gradient across the aortic valve. See
waveform sheets for details.

ANGIOGRAPHIC DATA:
There is a single main origin to the coronary artery tree, which appears
to arise from the right coronary cusp. The left coronary system begins
with an extremely long left main coronary artery. It is unclear from
this study whether this passes between the aorta and pulmonary artery or
anterior to the aorta; however, the left main itself appears to show mild
ostial stenosis less than 20%. Due to the catheter engagement, it is
unclear whether this narrowing is artifact from catheter placement or
whether it is real. There is no evidence of disease throughout the
remainder of the left main prior to its division into left anterior
descending ramus intermedius and left circumflex arteries. The left
circumflex artery consists only of a high marginal, it is a small
nondominant vessel. The left anterior descending is a small type 1
vessel of a single diagonal. There appears to be a mild disease. It
just shows mild intermittent plaquing, but no hemodynamically significant
disease. The ramus intermedius is a small vessel with mild-to-moderate
diffuse disease. Maximal narrowing appears to be 30% to 40%. The right
coronary artery is a large dominant vessel with no evidence of
significant disease. There are some minimal irregularities in the distal
vessels. There is an extensively developed posterolateral artery which
likely functions at least partially in place of distal circumflex
marginals, which do not appear to be present. The left ventriculogram
shows ejection fraction of approximately 55%. No segmental wall motion
abnormalities. No significant aortic insufficiency or mitral
regurgitation. The aortic root appears to be normal in size.

IMPRESSION:
Congenitally anomalous coronary arteries. There is mild-to-moderate
plaquing in the ramus intermedius, which appears to be hemodynamically
insignificant. There are otherwise scattered mild luminal irregularities
which also appear to be hemodynamically insignificant, and there does
appear to be a 50% stenosis at the origin of the right coronary artery.
It is unclear whether this is secondary to catheter-induced spasm given
the unusual origin of the coronary system. The path of the left main
coronary artery is also indeterminate from this study.

RECOMMENDATION:
CT angiography to determine the course of the left main coronary artery
as well as to determine whether the possible stenosis at the origin of
the right coronary artery is indicated. We will attempt to arrange this
as an outpatient. If there is a significant right coronary stenosis or
if the left main coronary artery passes posterior to the aorta, surgical
intervention may be required.

Thank you so very much for your help!!


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## Jim Pawloski (Sep 18, 2009)

Cyndi113 said:


> Good morning,
> 
> I'm very new to cath coding and need help deciding if this heart cath may actually be billed as an LHC or a CTA. Please HELP!
> 
> ...



You are billing for a Left Heart Cath..  The CTA is a recommended procedure that the patient may have later.

Thanks,
Jim Pawloski CIRCC


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## Cyndi113 (Sep 18, 2009)

Good morning, 

Thank you, Jim!!


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