# Help with Left/Right Heart Cath/stents



## dgarri (Jan 25, 2012)

93461/26, 92982/LC, 92984/SVG/OM, I know this is incorrect.....my brain is fried today and I am just not getting it.  Can I get some input please and thanks so much.

Description of Procedure: Under sterile conditions and local anesthesia, an attempt was made to insert a sheath in the right femoral artery and the right femoral vein w/o success. Next, a 6-french sheath was inserted percutaneously in the left femoral artery and a 7-french sheath in the left femoral vein.  Next, an attempt was made to advace a Swan-Ganz catheter; however, the Swan-Ganz catheter would not advance beyond the left femoral vein.  Therfore, the Swan-Ganz catheter was removed and the right heart cardiac catherizations was abandoned.  

Next, the coronaries were visualized using a 6-french judkins left 5 and 6-french 3drc.  the saphenous vein graft was visualized using the same 6-french 3drc.  The LIMA was als visualized using the same 6-french 3drc.

At the end of the procedure, the decision was made to proceed with attempted angioplasty to the totally occluded proximal circumflex and if this was not successful, the plan was to do attempted angioplasty to impending closure of the saphenous vein graft to the circumflex. 

Next, the patient was given additional IV heparin in addition to the heparin drip.  she was started on Integrilin bolus and drip.  Next, a 6-french XB LAD 3.0 guiding catheter was used to attempt the angioplasty to the totally occluded proximal circumflex.  A 0.014 Asahi XT Fielder wire was used w/o success in crossing the total occlusion.  Next, a Transit catheter (Quick-Cross) was advanced over the wire for extra support.  Despite this, there was no success in crossing the total occlusionin the proximal circumflex.  Therefore, the decision was made to proceed with angioplasty to the impending closure of the saphenouse vein graft to the circumblex.  Next, a 6-french 3drc guiding catheter 2.0 x 20-mm balloon.  Following angioplasty to the proximal saphenouse vein graft of the circumflex, ther was TIMI 3 flow, which is an impovement from TIMI 1 flow, and the patient became pain free.  There was no residual stenosis.  At that point, the decision was made to maintain the patient on IV Integrilin for 24 hours and to call the procedure successful.  I did not feel that stenting would improve the flow at that point and I felt that putting a stent at that point may trigger a no-reflow phenomenon and, therefore, the procedure was deemed successful.  At the end of the procedure, a hand injection was done through the side are of the sheath in the left femoral artery and hemostasis was obtained by using Angio-Seal.  

Summary: 
1. The procedure was done in the setting of cardiogenic shock and intractable chest pain.
2. Known dilated cardiomyopathy by previous cardiac catherization with and ejection fraction around 25%.
3. Patent left internal mammary artery to the left anterior descending and impending closure of the saphenous vein graft to the first obtuse marginal branch, jumped to the second obtuse marginal branch.
4. Total occlusion of the proximal circumflex, total occlusion of the proximal right coronary artery with collaterals filling the distal right coronary artery and 70% stenosis in the mid left anterior descending.
5. Attempted angioplasty to the totally occluded circumflex w/o success in crossing the total occlusion.
6. Successful angioplasty to the subtotally occluded saphenous vein graft to the first obtuse marginal branch and second obtuse marginal branch.  The patient became pain free after angioplasty to the saphenous bein graft and the flow improved from TIMI w to TIMI 3.  the blood pressure also improved and the patient was no longe in cardiogenic shock.


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## dimmitta (Jan 26, 2012)

Looks to me like the following codes should be used:

93458 - LHC with coronary angiograms with/without LV gram
92982/LC - Angioplasty SVG to LC

You would not bill a combined right and left heart cath due to right heart cath attempted but not completed. You would only code one intervention. You code bypass grafts according to the vessel they are grafted to, and per coding guidelines you only code the highest intervention performed per vessel. The LC and the SVG to the LC are still considered one vessel for coding purposes. Hope this helps


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## dgarri (Jan 26, 2012)

Yes this helps.  And makes sense.  I was wondering about the discontuned Rt cath and I knew the LC / Svg are considered one vessel - my brain just wasn't getting it......I hate it when that happens.  I really made it out to be harder than it was.  Thanks again for such a quick response. 


dgarri


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## dimmitta (Jan 26, 2012)

I have days like that too, so I know how you feel  And I'm always happy to help!


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## dpeoples (Jan 27, 2012)

dimmitta said:


> Looks to me like the following codes should be used:
> 
> 93458 - LHC with coronary angiograms with/without LV gram
> 92982/LC - Angioplasty SVG to LC
> ...



I agree with the angioplasty code, but I don't think the criteria for a LHC were met. I would code 93455-59 instead.

HTH


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## dgarri (Jan 27, 2012)

Danny - so you would bill : 92982/LC, 93455/59  Cors & Bypass Gfts (Venous/Arterial) instead, not the LHC 93458.


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## dimmitta (Jan 27, 2012)

The best way to know for sure would be to ask the doctor if the catheter crossed into the left ventricle or left atrium. This is the criteria for whether a LHC is done or not. If he says yes, then code 93459 (mistakenly listed 93458 last night, my brain was fried too lol). If he says no then I agree with Danny, and would code 93455.


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## dpeoples (Jan 27, 2012)

dimmitta said:


> The best way to know for sure would be to ask the doctor if the catheter crossed into the left ventricle or left atrium. This is the criteria for whether a LHC is done or not. If he says yes, then code 93459 (mistakenly listed 93458 last night, my brain was fried too lol). If he says no then I agree with Danny, and would code 93455.




If you have access to the doc, ask for clarification. If the left ventricle or atrium were crossed then 93459 would be correct. Even then, the document should be revised to include this information. Not documented , not done.

HTH


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