# Diagnostic Coronary angiography



## TaitM (Jan 25, 2012)

I am really new to cardiology coding and hope someone can help me with this op note: Thank you in advance!!!  I am soooo confused.  

PROCEDURE:  Selective diagnostic coronary angiography, intravascular ultrasound imaging right coronary artery, percutaneous coronary intervention with PTCA and placement of sequential drug-eluting stents, right coronary artery

The right radial region was prepped and draped. Local anesthesia with2% xylocaine was applied.  A right radial arteriotomy was them completed utilizing a modifie Seldinger technique. A 6-French sheath was placed in the right radial artery.  The patient was administered heparin 3000 units intraarterial and verapamil 5mg intraarterial.  Selective diagnostic coronary angiography was conducted with a 5 French ultimate 1 catheter by injecting 5-7 mL of Isovue contrast in multiple projections.  We elected to complete intrvascular ultrasoundimaging to furhter assess the anatomic extent, severity and nature of obstruction in the right coronary artery to guide medical management.

The ostium of the right coronary artery was engaged with a #6-French Judkins right - 4 guiding catheter.  The patient was administered additional heparin sufficiant for a total bolus at 50 units/kg intravenous.  The patient was treated with a single weight-adjusted bolus of the glycoprotein 2b/3a inhibitor Integrilin.  A 0.014 balanced middleweight wire was advanced to the mid portion of the right coronary artery.  The wire could not be advanced beyond 2 regions of angiographically significant obstruction due to lack of guiding catheter backup support.  The Judkins right 4 cath was removed.  The ostium of the right coronary artery was engaged with a 6 French Amplatz right 1 guiding catheter.  A 0.014-inch balance middleweight guidewire was advanced to the distal aspect of the right coronary artery.  IV ultrasound imaging was then conducted utilizing a Volcano Eagle Eye platinum intravascular unltrasound imaging catheter.  The ultrasound imaging catheter could be advanced within the distal most region of obstruction.  Ultrasound imaging demonstrated severe eccentric fibrocalcific plaque with a minimal lumen cross-section area of 3.5 sq mm and a % cross-sectional area stenosis.  We elected to complete percutaneous coronary intervention for the lesion observed in the right coronary artery.  The lesions were predilated with a 3mm semi-compliant and noncompliant balloons at inflation pressures of 10-16.  We attempted to deliver a 3mm diameter, 28 mm length PROMUS drug-eluting stent to the distal aspect of the lesion.  Delivery of the stent was not feasible due to inadequate guiding catheter support.  We elected to predilate the lesion further and utilize a 3.5 diameter, 20 mm length balloon at inflation pressures of 12-16 atmospheres for durations of 15-30 secs.  The distal aspect of the lesion was then treated by placement of a 3mm diameter, 15 mm length PROMUS drug-eluting stent.  The stent was  ppositioned to cover the distal margin of the obstruction.  The stent was deployed using a single inflation at 16 atmospheres for a duration of 30 sec.  The 3 mm diameter, 28 length PROMUS drug-eluting stent was then placed to overlap the distal stent and cover the regions of residual sstenosis in the proximal aspect of the artery.  The sstent was deployed using a single inflation at 1t atmospheres for a duration of 30 sec.  The stents were then postdilated.  Intravascular ultrasound imaging was conducted following stent deployment and adjunctive high pressure post-dilation.  Intravascular ultrasound imaging demonstsrated an adequate result with complete and symmetric expansion of the stents, without areas of bowel apposition and with minimal lumen cross-sectiona area greater than 9 sq mm.


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## Jim Pawloski (Jan 25, 2012)

MLT1600 said:


> I am really new to cardiology coding and hope someone can help me with this op note: Thank you in advance!!!  I am soooo confused.
> 
> PROCEDURE:  Selective diagnostic coronary angiography, intravascular ultrasound imaging right coronary artery, percutaneous coronary intervention with PTCA and placement of sequential drug-eluting stents, right coronary artery
> 
> ...



Your codes are 93454-59 for Coronary Angio, 92978 for IVUS (ultrasound), and 92980 for the coronary stent with includes angioplasty.  If you are billing for the hospital, and the patient has primary Medicare insurance, then you code G0290 for the drug eluting stent.

HTH,
Jim Pawloski, CIRCC


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## TaitM (Jan 25, 2012)

Can I ask you why the 59 modifier?  This is professional only so I know I have to use a -26


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## dimmitta (Jan 25, 2012)

Jim is correct in the code selection. You would need the 59 modifier for the Coronary Angio because most insurances consider the cardiac catheterization codes to be included in any interventional procedure performed. However, it is ok to unbundle these as long as the cardiac cath was done as a diagnostic tool and the decision to perform intervention was made due to the findings from the cardiac cath and images. Which appears to be the case in your op note here


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## TaitM (Jan 25, 2012)

Thank you so much.  I appreciate it!!


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