# need help with coding baremetal stent



## bhargavi (May 26, 2015)

CLINICAL INDICATIONS                                                            
Acute inferior wall ST elevation myocardial infarction.                         

CLINICAL HISTORY                                                                
Mr. Clough is an 87 years old man with a medical history apparently significant 
for diabetes and pneumonia.  He presented by ambulance earlier today to the 
Kent General Hospital with complaints of chest pain.  His electrocardiogram 
revealed ST segment elevations involving the inferior leads concerning for an 
acute evolving inferior wall myocardial infarction. A heart alert was called 
and I was asked to evaluate the patient emergently for cardiac catheterization. 
We confirmed the presence of  ST elevations and symptoms consistent with an 
acute myocardial infarction, so the patient was transferred emergently to the 
cardiac catheterization laboratory for coronary angiography and possible 
intervention.

TECHNIQUE                                                                       
After obtaining consent, the patient was prepped and draped in the usual 
fashion. Approximately 10 milliliters of two percent Lidocaine anesthesia was 
administered to the right groin prior to placement of the arterial sheath.  
Under fluoroscopic guidance and using the modified Seldinger technique, a six 
French arterial sheath was placed without difficulty into the right femoral 
artery.  We then proceeded with coronary angiography utilizing hand injections 
of Visipaque contrast due to renal insufficiency through six French FL4, six 
French diagnostic FL4 and a JR4 guide catheter.  After the completion of the 
interventional procedure, we also performed left heart catheterization. For 
purposes of completeness, the left heart catheterization findings will be 
described here.

FINDINGS                                                                        
1.   The left ventricular pressure was 185/20 millimeters of mercury. The 
aortic pressure was 185/56 millimeters of mercury.  There was diffuse moderate 
calcification of the entire coronary tree.
2.   The left main is a large vessel which bifurcates into the left anterior 
descending and left circumflex branches.  There is osteal 30 percent disease in 
the left main without dampening of the pressure on catheter engagement.
3.   The left anterior descending is a large vessel which wraps the coronary 
apex and gives rise to two to three diagonal branches of significance.  Again, 
there is moderate calcification of the proximal to mid vessel.  In the proximal 
vessel there is smooth 30 percent disease.  In the mid vessel beyond the second 
diagonal branch there is a lengthy area of 70 to 75 percent stenosis with mild 
patchy disease beyond.  The first diagonal branch is small to moderate in 
caliber and has proximal 80 percent disease. The second diagonal branch is 
similar in size and has no significant disease.
4.   The left circumflex is a large, anatomically nondominant vessel which, for 
all intents and purposes, gives rise to two major obtuse marginal branches.  In 
the proximal left circumflex there is smooth 30 percent disease.  In the mid 
vessel before the origin of a large second obtuse marginal branch, there is a 
second area of disease of approximately 60 percent severity.  The first obtuse 
marginal branch is medium in caliber and free of disease. The second obtuse 
marginal branch is large in caliber and has patchy 30 percent disease.
5.   The right coronary artery is a large, anatomically dominant vessel which 
is 100 percent occluded in its proximal segment, with TIMI Grade 0 flow beyond. 
There is minimal collateralization of a diseased PEA from the left coronary 
system.

After identification of acute occlusion of the right coronary artery, we went 
about attempting percutaneous intervention. The existing six French sheath was 
maintained in place.  Heparin at a dose of 5000 units by intravenous bolus was 
administered to achieve an activated clotting time in excess of 200 seconds.  
Later during the procedure, due to a large thrombus burden in the right 
coronary artery, Integrilin by intravenous single bolus and infusion at renal 
dosing, was administered.  The right coronary artery had already been 
selectively engaged initially utilizing a six French JR4 guide catheter.  We 
then obtained a 180 centimeter Asahi Prowater straight wire which we initially 
attempted to advance beyond the point of occlusion. Although we were able to 
advance this wire beyond the point of occlusion, we were unable to advance it 
beyond a bend in the mid vessel despite the use of an undilated 1.5 by 8 
millimeters Emerge balloon for back up.  We made multiple attempts and, 
unfortunately, lost guide catheter position.  We made further attempts with the 
use of a whisper wire but again were unsuccessful. At this point in time, we 
decided to change our strategy.  We removed the JR4 guide catheter and obtained 
a six French IMA guide catheter to allow for extra back up. We then obtained a 
0.14 inch Asahi Miracle Brothers wire. With some difficulty, we were able to 
successfully advance it into the distal right coronary artery beyond the bend 
in the mid vessel.  We then performed multiple predilatations utilizing a 1.5 
by 6 millimeters mini Trek balloon times multiple overlapping inflations.  
Unfortunately follow-up angiography revealed no change in the occlusion in the 
right coronary artery.  We then elected to perform further predilatation.  This 
time, we obtained a 2.0 by 12 millimeters Mini Trek balloon and performed 
multiple overlapping inflations from the early distal vessel back to the 
proximal vessel.  Follow-up angiography did transiently reveal re-establishment 
of flow into the distal right coronary artery with what appeared to be a large 
thrombus burden just prior to the distal bifurcation, perhaps also with flow 
limiting dissection in the mid portion of the right coronary artery.  This was 
followed on repeat angiography with reocclusion of the right coronary artery   
We then decided to perform further predilatation.  In this case, we obtained a 
2.0 by 30 millimeters Emerge balloon and performed multiple overlapping 
inflations of the proximal, mid and distal vessel using this balloon up to 12 
atmospheres of pressure times one minute at a time, times multiple overlapping 
inflations.  Follow-up angiography after 200 micrograms of intracoronary 
nitroglycerin revealed resumption of TIMI Grade II-III flow into the distal 
right coronary artery branches which constituted a small to moderate size 
posterior descending and posterior lateral arcade.  The area of thrombus had 
improved but there was clearly still disease throughout. We then elected to 
perform stenting of this vessel.  By this point, we had exchanged the Asahi 
Miracle Brothers wire for a standard Asahi wire and then obtained a second 
Asahi wire for back up and as a buddy wire.  We then performed stenting of the 
right coronary artery from just before the distal bifurcation to the ostium of 
the vessel utilizing from distal to proximal 2.5 by 28 millimeters, 2.75 by 28 
millimeters, 2.75 by 28 millimeters, 2.75 by 23 millimeters, and 2.75 by 12 
millimeters multi link mini vision stents.  Follow-up angiography after stent 
deployment revealed TIMI Grade III flow throughout the right coronary artery 
with evidence of a flow limiting lesion in the posterior descending branch in 
an area that was too small to allow for percutaneous intervention.  We, 
therefore, decided to medically manage this area. We did, however, perform post 
dilatation of the entirety of the stented segment utilizing a 2.75 by 15 
millimeters NC Quantum Apex balloon deployed over multiple overlapping 
inflations from distal to proximal from 16 all the way up to 22 atmospheres of 
pressure. Follow-up angiography after stent deployment and post dilatation 
revealed an excellent angiographic result with no residual stenosis and no 
evidence of proximal to distal edge dissection edge dissection, thrombosis or 
spasm.  There was TIMI Grade III flow in the vessel and the patient's chest 
pain had practically resolved. We, therefore, elected to conclude the 
angioplasty procedure. The coronary guidewires were removed and final 
angiography revealed a stable appearance of the right coronary artery. We then 
concluded the angiographic procedure as well.

Nonselective injection of the right ileofemoral system revealed acceptable 
position of the arterial sheath in the distal right common femoral artery above 
the common femoral bifurcation.  There was no angiographic evidence of disease 
at the site of sheath insertion and as such, a six French Angio-Seal was 
deployed for hemostasis.  The patient was then transferred to the recovery area 
in stable condition.  Of note, the patient did have intermittent atrial flutter 
with a controlled ventricular response competing with sinus rhythm and two to 
one AV conduction throughout the case.  At the end of the case, however, the 
patient was back in sinus rhythm with 2 1 AV conduction.

IMPRESSION                                                                      
1.  Mildly elevated LVEDP with severe systemic hypertension.                    
2.  Severe mid left anterior descending disease.                                
3.  Moderate left circumflex disease.                                           
4.  Acute occlusion of right coronary artery status post recannulization 
angioplasty and bare metal stenting times five.
5.  Status post Angio-Seal placement.                                           

PLAN                                                                            
Aspirin for life.                                                               
Plavix indefinitely.                                                            
Integrilin times 18 hours.                                                      
Aggressive risk factor modification including an echocardiogram and serial 
cardiac enzymes.
Other plans will depend upon the patient's clinical course.                     


thanks in advance
i was thinking of 93458-xu, c9606,c9600-rc since i am hospital coder










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## Chlrtrep (May 26, 2015)

bhargavi said:


> CLINICAL IMPRESSION
> 1.  Mildly elevated LVEDP with severe systemic hypertension.
> 2.  Severe mid left anterior descending disease.
> 3.  Moderate left circumflex disease.
> ...



IMHO

I would agree with 93458  however I believe only the right coronary artery was stented  therefore I would only code the AMI DES Revas  C9606 RC

Unless I missed another artery that was stented I do not see the need for       C9600.


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## espressoguy (May 27, 2015)

Chlrtrep said:


> IMHO
> 
> I would agree with 93458  however I believe only the right coronary artery was stented  therefore I would only code the AMI DES Revas  C9606 RC
> 
> Unless I missed another artery that was stented I do not see the need for       C9600.



I am not a hospital coder (although I do have one on speed dial  

I don't see where a DES was used. I was under the impression that the C codes are only used for a DES. The op report states in multiple places that bare metal stents were used. Why wouldn't this be 92941-RC?


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## Chlrtrep (May 27, 2015)

espressoguy said:


> I am not a hospital coder (although I do have one on speed dial
> 
> I don't see where a DES was used. I was under the impression that the C codes are only used for a DES. The op report states in multiple places that bare metal stents were used. Why wouldn't this be 92941-RC?



You are absolutely right I was so focused on the the  incorrect c codes I forget these were bare metal stents.  I am glad you caught that.....   I apologize to the original poster for the error.


C9606 and C9600 are for Drug Eluting Stents


92941   AMI Artery Re Vas using Bare Metal Stents


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## kejones0395 (Oct 8, 2015)

question on the change from 92928 to 92941----does the doctor have to identify that the procedure was urgent/emergent or just identify MI as the HPI?  I have one provider that is very precise and does both, so no question, but one only identifies MI, not that procedure done urgent/emergently.  Thanks


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## DeeLonna (Oct 9, 2015)

kristin.jones@mercyic.org said:


> question on the change from 92928 to 92941----does the doctor have to identify that the procedure was urgent/emergent or just identify MI as the HPI?  I have one provider that is very precise and does both, so no question, but one only identifies MI, not that procedure done urgent/emergently.  Thanks



The MD does need to state taken emergently to cath lab or you need to downcode.  Medaxiom BOCN is cardiac thoracic specialty coding training and they have an excellent website as well as free online webinars that are very indepth.  I too am fairly new to cardiology and MedAxiom helped immensely in getting me up to speed quickly.


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