# 93459 +



## amym (Nov 17, 2011)

Can I bill for the angiogram in addition to 93459 and what code would I use?

PROCEDURES PERFORMED: -- Left heart catheterization with ventriculography. -- LIMA graft angiography. -- Saphenous vein graft angiography. -- Saphenous vein graft angiography. -- Saphenous vein graft angiography. -- Saphenous vein graft angiography. 

RECOMMENDATIONS: Aortogram showed an extreme tortuosity of both R and L iliac arteries. LV gram and LHC not attempted. Non-selective native L coronary angiography showed proximal LAD disease but it's difficult to quantify the amount of stenosis. Native RCA angiography showed 90% prox and 100% mid occlusion. Non-selective LIMA to LAD showed widely patent graft. VG to Om1 showed proximal 50% stenosis. VG to OM2 was widely patent. VG to RPDA was widely patent. Pt is to conitinue med therapy and risk factor modification. 

INDICATIONS: CAD, positive stress test. HEMODYNAMICS: Hemodynamic assessment demonstrates moderate systemic hypertension. CORONARY VESSELS: The coronary circulation is right dominant. severe native CAD and patent CABG Left main: Normal. LAD: Angiography showed moderate atherosclerosis. Circumflex: Angiography showed moderate atherosclerosis. RCA: There was a 90 % stenosis in the proximal third of the vessel segment. In a second lesion, there was a 100 % stenosis in the middle third of the vessel segment. Graft to the LAD: The graft was a LIMA. Graft angiography showed no evidence of disease. Graft to the 1st obtuse marginal: The graft was a saphenous vein graft. There was a 50 % stenosis in the proximal third of the graft. Graft to the 2nd obtuse marginal: The graft was a saphenous vein graft. Graft angiography showed no evidence of disease. 
PROCEDURE: The risks and alternatives of the procedures and conscious sedation were explained to the patient and informed consent was obtained. The patient was brought to the cath lab and placed on the table. The planned puncture sites were prepped and draped in the usual sterile fashion. -- 

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. -- 

Left heart catheterization. A catheter was advanced to the ascending aorta. After recording ascending aortic pressure, the catheter was advanced across the aortic valve and left ventricular pressure was recorded. 
Ventriculography was performed using power injection of contrast agent. Imaging was performed using an RAO projection. -- 

Left internal mammary 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. – 

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. – 

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. – 

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. – 

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. 

COMPLICATIONS: There were no adverse outcomes. None occurred during the cath lab visit. 
PROCEDURE COMPLETION: The patient tolerated the procedure well. TIMING: Test started at 11:04. Test concluded at 12:29. 
RADIATION EXPOSURE: Fluoroscopy time: 33.3 min. 

STUDY DIAGRAM Angiographic findings Native coronary lesions: 7RCA: Lesion 1: 90 % stenosis. Lesion 2: 100 % stenosis. Coronary graft lesions: 7Graft to OM1: SVG [Graft not pictured] 7 Proximal 1/3 lesion 1: 50 % stenosis in proximal graft. HEMODYNAMIC TABLES Pressures: Baseline Pressures: - HR: 78 Pressures: - Rhythm: Pressures: -- Aortic Pressure (S/D/M): 167/78/115 Outputs: Baseline Outputs: -- CALCULATIONS: Age in years: 79.76 Outputs: -- CALCULATIONS: Body Surface Area: 2.12 Outputs: -- CALCULATIONS: Height in cm: 175.00 Outputs: -- CALCULATIONS: Sex: Male Outputs: -- CALCULATIONS: Weight in kg: 97.10 DICTATED BY: 23481


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## Jim Pawloski (Nov 17, 2011)

amym said:


> Can I bill for the angiogram in addition to 93459 and what code would I use?
> 
> PROCEDURES PERFORMED: -- Left heart catheterization with ventriculography. -- LIMA graft angiography. -- Saphenous vein graft angiography. -- Saphenous vein graft angiography. -- Saphenous vein graft angiography. -- Saphenous vein graft angiography.
> 
> ...



I hate to say this, but all you have is LHC with grafts - 93459


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## rpcarrillo (Dec 8, 2011)

I don't even think you really have a 93459 there, technically. The MD mentions that LHC and LV were not attempted. The LV is not a critical component of 93459, but the LHC is.

_93459 - Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography_

Knowing that an LHC was not performed, going to the next code 93455 still remains problematic with this documentation.

_93455 - Catheter placement *in* coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) *in* bypass graft(s) (internal mammary, free arterial venous grafts) including intraprocedural injection(s) for bypass graft angiography_

There are still gaping problems marrying 93455 to this very strangely worded documentation. Even though he/she mentions findings, your MD mentions more than once that both the native and SVG/IMA angiograms are non-selective. He mentions non-selective angiography a couple of times under the "Recommendations" heading. And again when describing the LIMA and SVG angiography in the body, he/she claims the catheter was advanced to the aorta and placed "at" the aortic anastomosis of the graft. I hate to lawyer up here, but "at" does not have the same meaning as "in". "At" signifies to me that the catheter lies outside of the grafts, and not "in" them. The code description clearly requires selectivity of both native and grafts, and from what is dictated here, that's not what occurred.

So, if you have non-selective angiography and are essentially shooting contrast from the aortic root, you'd think that the closest match would be 36200 and 75650, but frankly I wouldn't feel comfortable at all with that either since the intent is clearly to image the coronaries and grafts.

All the documentation in this case is highly, highly unusual. I would make it a priority to discuss with your physician how you can work together to improve their documentation. These really are some basic, fundamental cath lab documentation issues that need to be resolved before you can tackle anything else.

Hope this helps,
Rich


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## Jim Pawloski (Dec 8, 2011)

rpcarrillo said:


> I don't even think you really have a 93459 there, technically. The MD mentions that LHC and LV were not attempted. The LV is not a critical component of 93459, but the LHC is.
> 
> _93459 - Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography_
> 
> ...



I agree with you, and disagree with you.  It is a strange report.
Where I agree with you is with the LV.  The report states after the access, that a pigtail catheter was placed in first the ascending aorta, then advanced into the LV.  But you need a pressure measurement, End diastiloc pressure, or LV gram to be able to say left heart.  
Where I disagree is about the bypass grafts.  The LIMA is considered one of the bypass grafts, and since they are all bundled together, SVG's and IMA's, you can say coronaries and grafts.
As with 36200 and 75650, 36200 is bundled with the coronary angio., and 75650 is an arch arteriogram, must mention head and neck.  For Aortic root, you code 93567.  
We also missed G0278 for the non-selective pelvic injection.

Thank you for your opinion,
Jim Pawloski, CIRCC


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## theresa.dix@tennova.com (Dec 9, 2011)

Jim and rpcarrillo,

 Well  this is something. I agree with both of you to the point that this is a unusal report. Contradictory in places. The "recommendation" part is confusing and frankly Im not sure what that is.

But never mind that. Go on down to the Procedure. Puncture site right femoral. cath advanced to the ascending aorta and pressures recorded. Then it says catheter was advanced across the aortic valve (left heart cath right there)! It goes on to say Ventriculography was performed using power injection of contrast agent. LV is not a criteria for left heart cath BUT if one is done which this report says it was, that would be enough for a left heart cath. In order to do  a LV the aortic valve has to be crossed.Right?

Ok Jim I dont see where there: was a G0278 done. I see some sort of result of iliacs tortuosity. But not a distal aortogram. This is difficult but I would code this as;

93458 and 93567 I think that is the best you can do and I also think if questioned by an auditor you could make your case.

Now what do you both think of that?


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## Jim Pawloski (Dec 9, 2011)

theresa.dix@ethc.com said:


> Jim and rpcarrillo,
> 
> Well  this is something. I agree with both of you to the point that this is a unusal report. Contradictory in places. The "recommendation" part is confusing and frankly Im not sure what that is.
> 
> ...



Hi Theresa,
As to G0278, it is titled Non-selective Iliacs, so you don't really need aorta.  As for LHC, I have read and heard in a conference that you need either pressure measurement, or LV gram report.
That's my opinion,
Jim


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## theresa.dix@tennova.com (Dec 12, 2011)

Yes g0278 is non selective iliacs. Here is the description of the code;

G0278 : ILIAC AND/OR FEMORAL ARTERY ANGIOGRAPHY, NON-SELECTIVE, BILATERAL OR IPSILATERAL TO CATHETER INSERTION, PERFORMED AT THE SAME TIME AS CARDIAC CATHETERIZATION AND/OR CORONARY ANGIOGRAPHY, INCLUDES POSITIONING OR PLACEMENT OF THE CATHETER IN THE DISTAL AORTA OR IPSILATERAL FEMORAL OR ILIAC ARTERY, INJECTION OF DYE, PRODUCTION OF PERMANENT IMAGES, AND RADIOLOGIC SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE..

it does say cath placement in the distal aorta or same side femoral or iliac artery. In this case the report says aortogram  but no mention of the distal aortogram. It seems to me the aortogram was up high to look at the grafts and it ran down to the iliacs. The left heart cath can be determined by Pressures and LV gram done but also if the aortic valve is crossed with out LV gram done. This is a difficult report.  I appreciate your opinion. Interested to know what others think.


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