# Cardiac Stenting



## Tvuong (May 14, 2014)

Report of Coronary Intervention


Summary
Selective coronary angiography with placement of four coronary stents requiring balloon angioplasty alone of middle left anterior descending to gain access to distal stenotic disease in the left anterior descending. 


Summarized anatomy is as follows:

1) Patent native right coronary artery. 
2) High grade proximal left anterior descending disease with the proximal left anterior descending being a source of blood flow into a large diagonal branch. 
3) Patent left internal mammary artery to the mid left anterior descending with severe distal native left anterior descending disease distal to the distal anastomotic site of the LIMA. 
4) High grade circumflex trunk disease and critical stenosis of the first obtuse marginal branch. 


Procedure
A Q4 6 fr guiding catheter was placed in the left main. A choice floppy wire was used to gain access to the circumflex trunk. The severe stenosis in the circumflex trunk was crossed. Angiographic assessment then did not reveal a high grade obtuse marginal origin stenosis. The obtuse marginal vessel arose from the same area where the circumflex had severe disease. Because the obtuse marginal origin stenosis was not appreciated initially, a stent was successfully deployed in the circumflex trunk using a double wire technique.


Attention was then placed toward the left anterior descending. A choice floppy wire was used to access the left anterior descending and a lone stent was placed there to relieve stenotic disease compromising flow into a moderately large diagonal branch. 


Further angiographic analysis of the diseased LAD showed a stump where the LAD was sub-totally occluded after the diagonal branch vessel takeoff. With technical difficulty, the LAD subtotal stenosis was then crossed and the guidewire was advanced as far as possible into the distal LAD and across the high grade mid to distal LAD stenosis. The subtotal or total middle left anterior descending stenosis was then serially dilated with 15 mm and then 20 mm balloon. The 20 mm balloon was then advanced and the distal LAD stenosis was ballooned and stented. 


In the process of performing multiple angiographic views of the three distinct areas where stents had been placed, a critical stenosis was then noted at the origin of obtuse marginal branch across which the first stent had been placed in the circumflex trunk. 


Because circulation to the left anterior descending appeared very much improved, attention was then directed to the first obtuse marginal vessel. Multiple attempts employing double wires were made to gain access to the OM branch. This was not possible. Three separate wires were used. After the circumflex trunk wire was totally withdrawn, it did prove possible to access the OM branch through it?s very tight origin.
The OM origin stenosis could not be crossed initially with a 20 mm balloon.   The balloon was then downsized to a 15 mm balloon. The 15 mm balloon crossed the OM origin stenosis and was dilated. Then the 15 mm balloon was exchanged for a 20 mm balloon.  Y-stenting was then performed. The circumflex trunk was then rewired and dilated after the OM stent had been deployed and post dilated.


At the end of the procedure, the bifurcation stenting procedure in circumflex and obtuse marginal vessels appeared very satisfactory, as did the flow through the stent deployed in the proximal LAD which supplied significantly improved flow to a moderately large diagonal.   The distal LAD stent allowed improved flow through the bypass graft distally into the distal LAD territory. 


Procedure length: 3 hours, 30 minutes


Based on above report, should I bill 92928 twice (92928-LC, 92928-LD) and 92929-LC?


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## Jim Pawloski (May 19, 2014)

Tvuong said:


> Report of Coronary Intervention
> 
> 
> Summary
> ...




I would code it that way.
THANKS,
Jim Pawloski, CIRCC


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