# 93458-26 and 93503-59?



## Lisa Bledsoe (Sep 25, 2014)

Normally I would not code these together, but please see the report below.  Two separate approaches...

PROCEDURE NAME:  Right and left heart catheterization with *right heart  catheterization performed from an internal jugular approach using  ultrasound-guided Micropuncture access*, left heart catheterization with  coronary angiography performed from a right radial approach.


INDICATIONS:  The patient is a 69-year-old admitted with advanced right heart  failure.  She has been diuresed 13 or 14 pounds since admission.  Initial  brain natriuretic peptide level was 320.  She has chronic hypoxemic  respiratory failure on high flow oxygen with severe obstruction on prior PFTs.  She has chronic atrial fibrillation.  Echocardiogram during this admission  shows moderate to severe right ventricular enlargement, severe or close to  severe right ventricular systolic dysfunction, very severe right atrial  enlargement, a dilated IVC and a peak TR velocity of around 4 meters per  second suggesting severe pulmonary hypertension.  She has a prior history of  sarcoidosis.  She is a former cigarette smoker.  requested  bi-catheterization.


PROCEDURE:  The patient was taken to the catheterization lab in the fasting  state on oxygen therapy.  The right neck and the right wrist area were  prepared and sterilely draped in the usual fashion.  *Using ultrasound guidance  and a micropuncture catheter technique, access was gained easily to the right  internal jugular vein and an 8-French hemostatic sheath positioned.  A  Swan-Ganz catheter was advanced and pressure was recorded in the right atrium,  right ventricle, pulmonary artery and pulmonary capillary wedge positions.  Measured O2 consumption on 40% oxygen was acquired.  These data may not be  accurate.  Fick cardiac output was calculated after withdrawing blood from the  pulmonary artery for O2 saturation analysis and using the arterial oximetry  data.  Next, thermodilution cardiac outputs were recorded.*
Next, attention was turned to the right wrist and using a Terumo radial artery  access skid and a short 6-French slender sheath, access was gained to the  radial artery. The 6-French sheath was positioned without difficulty.  Four  thousand units of heparin were given as an intravenous bolus.  Two milligrams  of verapamil were given through the radial artery sheath.  A 5-French Jacky  catheter was advanced over a Rosen wire and the left coronary cannulated.  Cineangiography was performed in standard views.  Jacky catheter was then  manipulated to perform right coronary angiography in standard views. Using a  Glidewire, the Jacky catheter was advanced into the left ventricle and  pressure recorded.  A pullback was recorded across the aortic valve.  Closing  pressure was recorded.  The Jacky catheter was withdrawn using the Rosen wire.  A TR band was used to remove the arterial sheath from the right radial  artery.  Hemostasis was achieved.  The Swan-Ganz catheter was withdrawn.  The  venous sheath was withdrawn using manual pressure.  Hemostasis was achieved  and the patient was transferred to 3 North in stable condition without  complication of the procedure.


RESULTS:
HEMODYNAMICS:  On oxygen, saturations hovered around 90%.

Mean right atrial pressure is 13 mmHg.  RV pressure 90/13.  PA pressure 90/40  with a mean of 60.  Pulmonary capillary wedge pressure mean 12 to 15 with  respiratory variation.  Aortic pressure 125/70.  LV pressure 125/15 to 17.  Mean LV end-diastolic pressure visually less than 15 mmHg.

Thermodilution cardiac outputs averaged 2.7 L per minute with a cardiac index  of 1.35 L per minute.  Measured Fick cardiac output with O2 saturation  arterial 90% and PA saturation 63% 3.9 L per minute with a cardiac index of  2.0 L per minute.  Pulmonary vascular resistance 18 Wood units from  thermodilution cardiac output and 12.3 Wood units from Fick cardiac output.

CORONARY CINEANGIOGRAPHY:  The left main coronary is free of obstructive  narrowing, gives rise to an LAD diagonal system and a circumflex marginal  system.  There is evidence of left coronary to cameral fistula with  calcification of the LV cavity during left coronary injection.  There is mild  diffuse plaque in the left coronary system without obstructive narrowing in  the LAD diagonal system or in the circumflex marginal system.  The right  coronary is angiographically dominant.  There is angiographic evidence of  plaque without obstructive narrowing.

FINAL CATHETERIZATION DIAGNOSES:

1.  Persistent severe pulmonary hypertension despite high flow oxygen,  maintaining O2 saturations during this procedure around 90%.  Mean PA pressure  60.

2.  Severe elevation in pulmonary vascular resistance (pulmonary hypertension  is mostly precapillary).

3.  Mild to moderate elevation in systemic venous pressure despite 13 L  diuresis consistent with severe RV systolic dysfunction.  

4.  Upper normal or mild elevation in pulmonary capillary wedge pressure.  

5.  Low resting cardiac output.

6.  Nonobstructive coronary plaque in the left and right coronary system.  

7.  Coronary cameral fistula with left to left shunting.

COMMENT:  The role of pulmonary arterial hypertension drug therapy in a  patient with severe pulmonary dysfunction, chronic hypoxemia and difficult to  control persistent severe pulmonary hypertension is at best uncertain.


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## sheilacpc (Sep 25, 2014)

Lisa, 

As per CPT coding guidelines: "Do not report CPT code 93503 in conjunction with other diagnostic cardiac catherization codes".  

I don't see where the guidelines stipulate that it would be acceptable if two separate approaches are done, then it would be O.K. to code both together.

Sheila


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## Jim Pawloski (Sep 25, 2014)

Lisa Bledsoe said:


> Normally I would not code these together, but please see the report below.  Two separate approaches...
> 
> PROCEDURE NAME:  Right and left heart catheterization with *right heart  catheterization performed from an internal jugular approach using  ultrasound-guided Micropuncture access*, left heart catheterization with  coronary angiography performed from a right radial approach.
> 
> ...



93503 is used when a Swan-Ganz catheter is placed in the pulmonary artery and is left there for monitoring in the ICU.  You have a 93460, Right and Left Heart Cath.


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## Lisa Bledsoe (Sep 26, 2014)

Jim - even with 2 separate access sites?


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## Jim Pawloski (Sep 27, 2014)

Lisa Bledsoe said:


> Jim - even with 2 separate access sites?



Why not?  You can do this with two accesses in the femoral artery and femoral vein.


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## Lisa Bledsoe (Sep 29, 2014)

True...thank you.


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