# 93458



## shescka (Mar 13, 2015)

Hello,
I'm new in cardiology and my understanding is that when left heart cath is done, the cath has to pass the aortic valve. Once it is inside the left ventricle of the pt's heart. Inside the ventricle it is where the pressure measurements and or ventriculogram are taken. 
If the LVEDP is not taken like in this example below, should still use 93458?
This is how I coded : 92943, 93458,26,59
thank you in advance for your time


BRIEF HISTORY:

This is a 53-year-old male with a history of HIV, hypertension,

smoking with questionable medical compliance with medications, who

presented with complaints of intermittent chest pressure for the last

24 hours that woke him up early in the morning, at which time he

presented to the ER with an EKG showing inferior ST elevations with Q-

waves along with CTS class 4 angina for which he was referred for an

emergent left heart catheterization.



DESCRIPTION OF PROCEDURE:

After informed consent was obtained, both groins were prepped and

draped in a sterile fashion and using the mini stick, right femoral

arterial access was attempted, but the micropuncture wire did not pass

freely into the femoral artery due to which the 6-French MS sheath was

placed in the left femoral artery, and angiogram confirmed normal

sheath positioning, after which a 6-French JL4 catheter was used to

obtain left coronary angiography followed by a 6-French JR4 guide

catheter used to obtain right coronary angiography. A thrombotic

occlusion was noted in the mid LAD at which time, we prepared for PCI

to the LAD. IV Angiomax was administered to maintain adequate

anticoagulation. After attempting to cross the mid RCA lesion with a

long Prowater wire unsuccessfully, we then across the mid-LAD lesion

with a 300 cm PT 2 wire over a FineCross after which a Pronto LP was

used to perform aspiration thrombectomy of the mid to distal RCA. A

double bolus of IV Integrilin was administered due to the high

thrombotic burden and it was confirmed that the Pronto catheter did

extract a small amount of clot from the RCA. We then pre-dilated the

mid RCA lesion with a 2.5 x 12 mm Emerge compliant balloon to 12

atmospheres after which Pronto LP aspiration thrombectomy was again

performed. This restored flow in the RCA. We then exchanged the PT 2

wire for a long Prowater wire over a FineCross and a 5-French MS

sheath was placed in the left femoral vein in case the patient needed

a temporary pacemaker during the PCI. We then successfully deployed at

3.0 x 12 mm Rebel bare metal stent in the mid RCA to 12 atmospheres

after which we post dilated the stent with a 3.25 x 12 mm NC balloon

in its proximal to mid section to 14 atmospheres. This gave a

favorable angiographic result with good stent apposition and no

evidence of dissection. There was TIMI 0 flow in the distal RCA prior

to the PCI and TIMI-3 flow in the distal RCA post PCI. The mid RCA

lesion was 100 percent occluded prior to the PCI and 0 percent

residual stenosis post PCI. There was a small amount of thrombus

embolized in the very distal right coronary artery, which we did not

intervene on as there was TIMI-3 flow in the distal RCA beyond this

thrombus. A 6-French Angio-Seal was then successfully deployed in the

left femoral artery to achieve hemostasis. There were no complications

during the procedure and the patient tolerated the procedure well.



ANGIOGRAPHIC FINDINGS:

1. Left main with no angiographic stenosis.

2. Mid LAD has a mild up to 30 percent focal stenosis.

3. Left circumflex has no angiographic stenosis.

4. Right coronary artery has a mid segment thrombotic total occlusion.

5. Dominance: Codominant.



POSTOPERATIVE DIAGNOSIS:

Successful PCI to the mid RCA with a 3.0 x 24 mm Rebel bare metal

stent post dilated to 3.25 mm after successful Pronto aspiration

thrombectomy.


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## Shipman.Meric (Mar 14, 2015)

*LHC not documented*

I don't see any documentation that a catheter was passed into the LV or across the aortic valve, and no findings. I would not code the LHC, leaving you with 93454, coronary angiography only. A total occlusion is documented, however, this appears to be an acute event with ST elevations. 99243 is not appropriate. So the PCI to the RCA would leave 92928, or 92941 if an acute MI was actually documented. It would seem with the acute event, inferior ST elevations, total occlusion of the RC and thrombus burden this would be the case. Query for specific diagnosis. 

BTW, I'm not exactly sure what kind of coronary anatomy is present when guide wires and caths are going from the LD to the RC. I'd probably query for a clear documentation/report. 

M. Shipman


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## j.monday7814 (Mar 16, 2015)

yep, not enough documentation to support the LHC. it doesn't look like the physician ever attempted or planned to cross the aortic valve...which may be another indication that this was an acute MI and he was more concerned with immediate intervention. I don't think there is enough documentation to support 92941, I would use 92928.

the issue with the LAD to RCA look like typos to me...or bad dictation. it would be nice to have consistency throughout the report but not absolutely necessary.


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## CardioCoder79 (Mar 16, 2015)

IMO - I would use 93454-26-59 (coronaries only) and 92941-RC (Stent). No LV gram is documented and it doesn't state that he crossed the AV. He does state that the RCA is 100 percent occluded and the 92941 is for a total or subtotal occlusion and includes the aspiration thrombectomy when performed. Hope this helps.


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## j.monday7814 (Mar 16, 2015)

rsenn1979 said:


> IMO - I would use 93454-26-59 (coronaries only) and 92941-RC (Stent). No LV gram is documented and it doesn't state that he crossed the AV. He does state that the RCA is 100 percent occluded and the 92941 is for a total or subtotal occlusion and includes the aspiration thrombectomy when performed. Hope this helps.


yes, but 92941 is for acute occlusions during an acute MI, this case was not identified as acute and the physician did not diagnose it as an MI...only ST elevation. Personally, I would ask the physician to document those key words so that there is no question whether or not this supports 92941


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## CardioCoder79 (Mar 17, 2015)

j.monday7814 said:


> yes, but 92941 is for acute occlusions during an acute MI, this case was not identified as acute and the physician did not diagnose it as an MI...only ST elevation. Personally, I would ask the physician to document those key words so that there is no question whether or not this supports 92941



Agreed. He does need to clearly document that the occlusion is acute and that there was in fact an acute MI. That way, there is no doubt about using 92941.


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## shescka (Mar 19, 2015)

Many thanks for your comments, I've learned a lot


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