# Help...Left heart cath with stent



## Goyard71 (Aug 6, 2013)

Can pls someone tell me if I coded this procedure right? I am not certain about 92929. Your help is really appreciated....

Thank you!!!!

We are blling for physician services.

93458-26,59
92928-RCA
92929-RCA

PREOPERATIVE DIAGNOSIS
1.	Acute inferior ST – segment elevation myocardial infarction, post 100%
2.	Stenting of the right coronary
3.	Clot extraction

POSTOPERATIVE DIAGNOSIS:

PROCEDURE(S) PERFORMED:
1.	Coronary angiography
2.	Percutaneous coronary intervention of 100% right coronary artery with ballooning and 2 stents placed.
3.	Thrombectomy
4.	Distal injection of intracoronary adenosine
5.	Measurement of left ventricular end-diastolic pressures

PROCEDURE: The patient was taken emergently from the ER to the catheterization lab with evidence of acute inferior myocardial infarction, was prepped and draped in the usual fashion. 

Using 2% local Xylocaine, the right femoral region was entered. An introducer sheath was placed, through which a 4 left Judkins was advances to the opposite left coronary artery. Several hand injections visualized the artery in various projections. This catheter was removed and replaced with a 4 right Judkins guide which was advances to the right coronary artery. This was found to be 100% conclude. Angiomax was given and then p.o. Brilinta was given.

A 2.0 balloon was prepared and a 0.014 Sport wire was prepared. The wire was advanced down the artery across the lesion into the distal vessel, and then the balloon was advanced over the wire with some difficulty, having to go through a revealed flow to the artery, but there was a marked clot just distal to the balloon inflation. The balloon was then removed and an Export catheter was brought to the point of the lesion, and then several runs were made along the distal portion of the lesion and farther down and then substantial clot was considerably narrowed. Blood pressure was in the mid 70s to low 80s. The patient was given wide open IV fluids, and at that juncture a 2.5 balloon was brought to the point of the elongated lesion and inflated with full expansion, and then subsequently a 3.0 x 23 zotarolimus stent was placed across this lesion and fully expanded up to 14-16 atmospheres. Angiograms showed a significantly improved area.

At this juncture there was found to be a substantial lesion above the previously placed stent. This was then stented with another 3.0 x 13 zotarolimus stent and fully inflated up to 14-16 atmospheres. The balloon was pulled back. Angiograms showed a markedly improved area, but it was felt that there may be some spasm distally, and it was elected also to give intracoronary adenosine distally. This was given 100 mcg at a time up to 600 mcg, and then the catheter was removed. In order to deploy both stents, we had to use a dual wire technique because of somewhat limited guide support. A Grand Slam wire was used along the Sport wire. The pressure began to rise to 85-90 and then up to 100. ST segments were resolving to normal, He did have evidence of idioventricular rhythm.

The wire was removed and the guide was then removed.

A pigtail catheter was advanced to the aortic arch and then the left ventricle. Pressures were recorded. Left ventricular end-diastolic pressure was 20-25. The catheter was then removed. The injection in the femoral sheath showed good position, and then the sheath was removed and the artery was closed with Angio-Seal. The patient tolerated the procedure fairly well. He was given 50 mcg of fentanyl for pain and conscious sedation as well as 1 mg of Wersed.

The patient was in sinus rhythm with good blood pressure with TIMI-3 flow to the artery at the time of transfer to the intensive care unit.

ANGIOGRAPHIC DATA:
1.	Coronary artery disease, inferior ST – segment elevation myocardial infarction. The LAD shows a previously placed stent. The LAD in general has plaquing but without significant stenosis. The circumflex is a substantial-sized artery and has a somewhat elongated 70% to 80% major obtuse marginal branch lesion. The right coronary artery is 100% occluded in the mid to mid distal segment. There is a previously placed stent in the proximal coronary artery.
2.	Clot extraction from the 100% right coronary artery with subsequent placement of 2 drug-eluting stents to the more distal and then the more proximal portion of the lesion followed by intracoronary adenosine.
3.	Measurement of left ventricular end-diastolic pressures of 20-25.


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## Twixle2002 (Aug 6, 2013)

I would bill 93458-59
 and 92941 but I would only charge it once because it is not stated that the second stent was put into a branch of the rca.  It looks to me like it was an overlapping stent of the first stent done in the same vessel


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