# Procedure coding help



## loril1983 (Dec 28, 2016)

I need help coding this particular procedure, my manager and I disagree on the coding.  Please note the patient was brought back two hours later on the same DOS for another procedure. Any help would be appreciated!!

1st procedure at 12:30am

PROCEDURES PERFORMED:
• Left coronary angiography.
• Defibrillation.
• Right coronary angiography.
• Right femoral sheath sideport angiography.
• Percutaneous intervention on the 100% stenosis in the proximal LAD. Balloon angioplasty. Stent placement.

PROCEDURE:
1. Initial setup. The patient was brought to the laboratory. Surface ECG leads, blood pressure measurements, and pulse oximetric signals were monitored.
2. Skin preparation. The planned puncture sites were clipped, prepped, and draped in the usual sterile manner.
3. Local anesthesia. 1% Lidocaine was administered to the access site.
4. Right femoral artery access. A 6F x 11cm Prelude Pro sheath was advanced into the vessel.
5. Selective left coronary angiography. A catheter was advanced into the left coronary vessel ostium under fluoroscopic guidance. Contrast was injected. Images were obtained in multiple projections.
6. Defibrillation.
7. Selective right coronary angiography. A 6F FR4 Expo 100cm catheter was advanced into the right coronary vessel ostium under fluoroscopic guidance. Contrast was injected. Images were obtained in multiple projections.
8. Nonselective right femoral sheath sideport angiography for closure evaluation, under fluoroscopic guidance. Contrast was injected into the sheath side port. Images were obtained.

1st lesion intervention:
Percutaneous intervention on the 100% stenosis in the proximal LAD.
1. Balloon angioplasty. A 2.5 x 20 Emerge balloon was employed. The balloon was placed across the lesion and given a single inflation with a maximum inflation pressure of 12 atm.
2. Stent placement. A 3.5 X 24 SYNERGY (MR) DES stent was advanced across the lesion and deployed with a single inflation and a maximum pressure of 11 atm.

CORONARY ARTERIES:
LAD: Proximal vessel lesion: There is a 24 mm (L), 100% stenosis. This lesion is without evidence of thrombus and not a bifurcation lesion. There is TIMI grade 0 flow (no flow) across the lesion. The lesion is a likely culprit for the patients clinical presentation and an ACC/AHA type C 'high risk' lesion for intervention. The lesion was stented (see 1st lesion intervention). Following intervention, the lesion has TIMI grade 3 flow (brisk flow).

COMMENT: Comment: the patient presented with stemi and multiple episode of v fib which continued after the LAD was opened. the lad was stented with a nice result. There was no other disease. – End of report.


~~~~~~Pt. brought back for second procedure two hours later.~~~~~~~~

PROCEDURES PERFORMED:
• Left coronary angiography.
• Temporary pacing.
• Intra aortic balloon counter pulsation.
• Percutaneous intervention on the stenosis in the proximal LAD. Balloon angioplasty.

PROCEDURE:
1. Initial setup. The patient was brought to the laboratory. Surface ECG leads, blood pressure measurements, and pulse oximetric signals were monitored.
2. Skin preparation. The planned puncture sites were clipped, prepped, and draped in the usual sterile manner.
3. Local anesthesia. 1% Lidocaine was administered to the access site.
4. Selective left coronary angiography. A catheter was advanced into the left coronary vessel ostium under fluoroscopic guidance. Contrast was injected. Images were obtained in multiple projections.
5. Catheter exchange. The catheter was exchanged for a 6F XB 3.5 catheter.
6. Temporary pacing. A new 5F SwanGanz PCG was inserted and advanced to position under fluoroscopic guidance. Pacing was achieved. Threshold verification and amplitude adjustment was performed.
7. Intraaortic balloon pump placement. The femoral artery was cannulated. The balloon catheter was advanced into the aorta and the tip was fluoroscopically positioned just distal to the left subclavian artery origin. Balloon pumping was begun, adjusting inflation and deflation times to maximize diastolic augmentation and minimize presystolic LV afterload.
8. Right femoral artery hemostasis. The sheath was sutured in place.
9. Right femoral vein hemostasis. The sheath was sutured in place.
10. Right femoral artery hemostasis.

1st lesion intervention:
Percutaneous intervention on the stenosis in the proximal LAD. Balloon angioplasty. A 3.5 X 15 SC NC EMERGE MR balloon was employed. The balloon was placed across the lesion and given four inflations with a maximum inflation pressure of 16 atm.

CORONARY ARTERIES: The coronary circulation is codominant.
LAD: Prior intervention: drug eluting
stent in the proximal LAD, less than one month. Proximal vessel lesion: There is a 24 mm (L) instent. This lesion is not a bifurcation
lesion. There is TIMI grade 0 flow (no flow) across the lesion. The lesion is a likely culprit for the patients clinical presentation and an ACC/AHA type C 'high risk' lesion for intervention. An angioplasty was performed (see 1st lesion intervention). Following intervention, the lesion has a residual stenosis of 0% and TIMI grade 3 flow (brisk flow).

COMMENT: Comment: patient returned to lab after recurrent v fib and hypotension after LAD Stenting the LAD stent was closed he was put on Repro and Balloon angioplasty of the stent with a noncompliant balloon was performed. Next a balloon pump and temp pacer were placed. – End of report.


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## Jim Pawloski (Dec 30, 2016)

loril1983 said:


> I need help coding this particular procedure, my manager and I disagree on the coding.  Please note the patient was brought back two hours later on the same DOS for another procedure. Any help would be appreciated!!
> 
> 1st procedure at 12:30am
> 
> ...



I would code 93454-XU and 92941-LD (C9606-LD for hospital) for the first session. For the second session, I would code 93454-78 and 92920-ld-78.
HTH,
Jim Pawloski, CIRCC


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## loril1983 (Jan 12, 2017)

Jim Pawloski said:


> I would code 93454-XU and 92941-LD (C9606-LD for hospital) for the first session. For the second session, I would code 93454-78 and 92920-ld-78.
> HTH,
> Jim Pawloski, CIRCC




What about the coding for the defibrillation that was done on the first procedure? And what about the temporary pacing and balloon pump insert on the second procedure?


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## Jim Pawloski (Jan 13, 2017)

loril1983 said:


> What about the coding for the defibrillation that was done on the first procedure? And what about the temporary pacing and balloon pump insert on the second procedure?



For the defibrillation, it's the saying "you broke it, you fix it". Also the external cardioversion is an elective procedure, so it can't be billed in this case. If CPR was performed, then you can bill for that.

For this IABP and temporary pacemaker, That can be billed.

Jim Pawloski, CIRCC


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## aarias1206 (Jan 30, 2017)

loril1983 said:


> I need help coding this particular procedure, my manager and I disagree on the coding.  Please note the patient was brought back two hours later on the same DOS for another procedure. Any help would be appreciated!!
> 
> 1st procedure at 12:30am
> 
> ...



First Case. 92928/LD. 93454, can not be coded with ptca because its already bundled with the stent. If a LHC 93458 was done then you would be able to code together the Cath and the stent by added 26,51,59 to the Cath code.

Second Case:
Sean ganz- 93503, this is coded when it is left in a place and not remove from the PX.
Temporary pacing- 33210
Balloon pump-33968 insertion or removal 33967
Balloon angioplasty 92920/LD
Coronary 93454 is not to be coded with 92920 as it is included. Modifier 51 and 59 will need to be added in the second case with return to Cath lab 78 unplanned. 

Also 92941 is only to be coded when the patient let say goes to ER and there having an Acute myocardial infraction and the patient artery is totally occuled. I've been doing IP coding for 15 years. I hope this was helpful.


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## Jim Pawloski (Feb 1, 2017)

anarias@mhs.net said:


> First Case. 92928/LD. 93454, can not be coded with ptca because its already bundled with the stent. If a LHC 93458 was done then you would be able to code together the Cath and the stent by added 26,51,59 to the Cath code.
> 
> Second Case:
> Sean ganz- 93503, this is coded when it is left in a place and not remove from the PX.
> ...



Why can't the diagnostic be coded with the stent? I agree with the PTCA being bundled in with the stent.

Jim Pawloski, CIRCC


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## dpeoples (Feb 1, 2017)

here my 2 cents. (pro fee)
 first case
92941-LD (i21.3, i48.91)
93454-,59

case 2
92920-59,78 LD (T82.855A for In stent restenosis, I49.01)
93454-59,78
33967
pacer will bundle, no modifier. Swan ganz was used for pacer, not for monitoring. I would not code.

Modifier 51 depends on payor preference for 93454.

HTH


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