# Not sure what I'm doing.



## eagomar (Aug 3, 2009)

Hello...Don't really do much cardiology coding, but was asked to look at this report. Was hoping for some clarification when anyone gets a free moment. Like when do you use 36216 or 75756? This is what I think, but am totally not sure as there is a lot of info to digest from this 1 report. Thanks in advance for even reading this as well as any replies.

93510
93545
93555
93543
93556
93539
93540 

and then the confustion w/ 36216/75756

PROCEDURES PERFORMED
Percutaneous left femoral arterial and venous sheath insertion, left
heart catheterization, coronary angiography, angiography of the saphenous vein grafts, and angiography of internal mammary artery graft. Flow wire assessment of the first obtuse marginal branch and 6 French Angio Seal following arteriography of the left femoral artery.

TECHNIQUE
The patient was brought to the cardiac catheterization suite after premedication. The left femoral area was prepped and draped in the usual sterile fashion. Local anesthesia was obtained using 2% Lidocaine. Arterial access was obtained in the left femoral artery by the percutaneous approach using a 6 French sheath. No unusual features were encountered. Catheterization was performed using the catheters listed above and the standard techniques. After the procedure, the sheath was withdrawn and hemostasis was obtained by directed pressure. The patient tolerated the procedure well. After the diagnostic portion of the procedure the patient was taken to a flow wire assessment of the first marginal, which was performed with the administration of 40, 60 and then 80 mg of adenosine. He was
initially given 1500 units of heparin for the flow wire assessment, and then had a 6 French Angio Seal performed, as his ACT was greater than 200 post flow wire.

CORONARY ANGIOGRAPHY
1. The left main coronary artery is short and patent.

2. The left anterior descending artery contains a 60% stenosis proximally and is somewhat hazy at its origin. The LAD is large in distribution, wrapping around the apex where it bifurcates. The 1st diagonal is seen to fill a saphenous vein graft, which is widely patent. The diagonal was patent distal to the graft anastomosis. At its takeoff, however, from the left anterior descending artery contains a 90% stenosis. Additionally, there is a LIMA graft, which touches down into the midportion of the LAD distal to the diagonal graft. This graft is a portion of a Y graft formed by the left
internal mammary artery and the radial artery, which subsequently goes to the circumflex territory. The LIMA portion, which continues between the wide insertion of the radial graft and the LAD itself is atretic, but patent without stenosis. There is competitive flow noted in the LAD from native circulation, as well as from the 1st diagonal vein graft and it is felt that this is the reason why this particular segment of the graft is atretic, as there is adequate
native and other collateral flow. Distally the LAD is patent.

3. The circumflex system gives off a ramus intermedius branch, which is totally occluded but is seen to fill via a vein graft, which touches down proximally in it. Distal to the vein graft the ramus intermedius is patent. The vein graft to the ramus intermedius is also patent. The circumflex more distally contains a 90% stenosis in the distal circumflex. There is also a vein graft, which is noted to fill, however, the distal 3rd marginal. Does back fill a smaller 2nd marginal as well. The vein graft to the 3rd marginal is widely
patent. There is however a 1st marginal noted. In the circumflex around the takeoff of the 1st marginal there are a series of branch points and visually there appeared to be a stenosis, which could be severe as 70% to 80%. This was the lesion that was subsequently assessed by flow wire and had a negative change in FFR, running around 0.91 throughout despite adenosine at maximal dose of 80. A 6 French JL 4.5 guiding catheter was used for that portion of the
procedure.

4. The right coronary artery is small and has a 90% stenosis of the posterior descending artery proximally. There is a patent saphenous vein graft, which touches down in the posterior descending artery and is noted to be patent distal to the graft anastomosis. The vein graft to the right is also noted to be patent.

ANGIOGRAPHY
Subsequently angiography was performed of the left femoral artery, as the patient's ACT was high and after visualization proved that the stick site was adequately superior to the bifurcation, a 6 French Angio Seal was successfully deployed with good hemostasis. She also received Ancef 1 g due to the Angio Seal deployment. The common femoral artery appears widely patent, as do the origins of the superficial and deep.


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## Jess1125 (Aug 3, 2009)

I don't see any mention in the report of the physician crossing the aortic valve and going into the left ventricle. I would code

93508-26
93545
93556-26
93540
93539

We also have fractional flow reserve being done which is 93571-26.

I do also want to note that cardiac caths include the introduction, positioning and repositioning of the catheters.

75756 wouldn't be used for the internal mammary angiography during a cardiac cath.


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## eagomar (Aug 5, 2009)

Thanks for your help. Really appreciate it.


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