# Coding help Please - Left heart catheterization



## nancy.anselmo@ccrheart.com (Oct 5, 2012)

Left heart catheterization with selective coronary angiography, second order selective peripheral thoracic angiography, complex peripheral artery disease requiring multiple wires and technique.

HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old with history of tobacco abuse, hypertension, previous CAD with multiple percutaneous interventions in the past. Most recently intervene on the ostial RCA lesion back approximately 3 months 
prior. She presents with stuttering symptoms concerning and consistent with her previous angina and is referred for angiography with suspect restenosis or de novo lesion.

PROCEDURE: Informed consent was obtained and the patient understood the risks, benefits and alternatives procedure and agreed to proceed with the procedure. The right groin was prepped in the usual sterile fashion and 2% lidocaine infused 
subcutaneously until adequate anesthesia was obtained. Right common femoral artery was accessed using modified Seldinger technique of which a 6 French sheath was attempted. Micropuncture technique was utilized initially and it was difficult to pass a 
wire. Subsequently, a Terumo Glidewire was utilized eventually traversing the complex lesion seen in the common iliac artery on the right side and selective angiography demonstrated this. Eventually the wire was able to be traversed and catheters were 
able to be deployed. A 5 French system was used to perform selective coronary angiography on the right which demonstrated patent stent seen.

HEMODYNAMICS: Left ventricular end-diastolic pressure measured 12 mmHg. 

SELECTIVE CORONARY ANGIOGRAPHY:
LEFT MAIN: There was catheter dampening upon engagement of the left main coronary artery with the 5 French system. Patient experienced chest pain and ventricularization of pressures.

LAD: The left anterior descending artery had a patent stent with mild disease.

CIRCUMFLEX: There was a patent stent with mild disease as well as a high marginal that had about 30% proximal disease.

RCA: Diffuse disease and stents. There was an ostial stent that was patent, a midvessel stent that had about 20% stenosis and a distal stent with 50% in-stent restenosis.

Intravascular ultrasound was utilized to evaluate the ostial left main. Five thousand units of heparin were used and the sheath was up-sized to a 6 French system. An EBU 3.5 guide catheter was used to intubate the left main with the wire being placed 
into the circumflex. An IVUS catheter was used to evaluate the reference diameter which was 16 m2 and the stenotic ostium measured 4.7 mm2 consistent with an approximately 70% area stenosis and a critical value of the stenosis to less than 6 mm2, 
indicative of critical ostial left main.

SUMMARY: Multivessel coronary disease with high-grade lesion seen at the ostium of the left main as well as in the distal RCA with in-stent restenosis.

CLINICAL PATHWAY: The patient will be expedited for coronary artery bypass grafting by Dr. Ronald Kirshner with attention drawn to the left main as well as the RCA. Of note, due to the patient's severe peripheral artery disease, selective engagement of
the subclavian artery was performed. Selective angiography demonstrated tortuosity and mild stenosis seen in the proximal portion of the vessel. There is no pullback gradient. The vertebrals Were free of ostial disease. The wire was 
then advanced into the main body of the subclavian and an IMA catheter was used to selectively engage the internal mammary artery. She had previous lung surgery and concern was whether or not the LIMA remained in situ. Selective engagement demonstrated
patency of this vessel and would be a useful conduit for bypass.

SUMMARY: Successful percutaneous evaluation of subclavian and internal mammary artery as potential conduits for coronary bypass.  

 Dr wants a LHC 93458-26
                IVUS 92978-LC-26
and selective 2nd order pheripheral thoracic vessel
and subclavian S & I. I am not sure of the last two codes Thanks Nancy


----------



## olivers (Oct 5, 2012)

In reviewing the op report, it doesn't indicate the patient had a previous CABG therefore the selective arteries are billable with the S&I.

93458-26    LHC
92978-26,   LC
36247-59    IMA
75710-26,-59  S&I
75685-26,-59  S&I Vertebral (CPT does not use selective in the description)

Double check me and be sure the dx codes for each area are listed (occlusion/disease, etc. each artery)

Sharon Oliver, CPC, CPMA, CPC-I


----------



## nancy.anselmo@ccrheart.com (Oct 8, 2012)

Thank you for your help


----------



## nancy.anselmo@ccrheart.com (Oct 8, 2012)

I have just one more question why use 36247 and not 36246? 36246 is second order. Thank you Nancy


----------



## jewlz0879 (Oct 8, 2012)

I'm not sure I agree with 36247/78685. I do not see specific catheter placement in the vertebral to support 75685-26. Documentation states vertebrals were free of disease but that is due to the Subclavian S&I. 

If normal anatomy (arch) I would use either 36216 (R) subclavian or 36215 (Lt) and 75710-26.


----------



## CPCCODERII (Oct 9, 2012)

jewlz0879 said:


> I'm not sure I agree with 36247/78685. I do not see specific catheter placement in the vertebral to support 75685-26. Documentation states vertebrals were free of disease but that is due to the Subclavian S&I.
> 
> If normal anatomy (arch) I would use either 36216 (R) subclavian or 36215 (Lt) and 75710-26.



I agree with Julie...I dont think documentation supports using the vertebral codes.  I would use the codes she selected as well.


----------



## theresa.dix@tennova.com (Oct 9, 2012)

CPCCODERII said:


> I agree with Julie...I dont think documentation supports using the vertebral codes.  I would use the codes she selected as well.



Ok. Here is something to think about. 

 "The left vertebral and subclavian arteries were imaged from a catheter placed in the left subclavian artery (36215-LT)." 

this is something taken off of an explaination for an op report that I did not interpret.  I have not read the report above in detail but cath placement codes and imaging codes do not always equal each other as you can see from the statement above so it is possible that the vertrbral was imaged and reportable from a cath placment in the subclavian.


----------



## Misty Dawn (Oct 14, 2012)

nancy.anselmo@ccrheart.com said:


> Left heart catheterization with selective coronary angiography, second order selective peripheral thoracic angiography, complex peripheral artery disease requiring multiple wires and technique.
> 
> HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old with history of tobacco abuse, hypertension, previous CAD with multiple percutaneous interventions in the past. Most recently intervene on the ostial RCA lesion back approximately 3 months
> prior. She presents with stuttering symptoms concerning and consistent with her previous angina and is referred for angiography with suspect restenosis or de novo lesion.
> ...




It sounds like the Dr was checking the IMA for potiental CABG.  The IMA is included in the HTC code 93459 (*Native* or bypass).  Instead of selectively entering the IMA he took the shot from the subclavin which normally you would move thru to get to the IMA.  I would just code for the 93459-26 (Coronaries + LHC + Native/Bypass graft) and the IVUS 92978-LC-26. 

As for the vertebrals I do not see any medical necessity indicated and would not bill. 

Misty Sebert, CPC     
Coding Specialist/Hospital Coordinator    
Spokane Cardiology  Providence Heart Institute


----------



## dpeoples (Oct 15, 2012)

Misty Dawn said:


> It sounds like the Dr was checking the IMA for potiental CABG.  The IMA is included in the HTC code 93459 (*Native* or bypass).  Instead of selectively entering the IMA he took the shot from the subclavin which normally you would move thru to get to the IMA.  I would just code for the 93459-26 (Coronaries + LHC + Native/Bypass graft) and the IVUS 92978-LC-26.
> 
> As for the vertebrals I do not see any medical necessity indicated and would not bill.
> 
> ...



I agree with Misty.

HTH


----------



## CPCCODERII (Oct 16, 2012)

*"Of note, due to the patient's severe peripheral artery disease, selective engagement of
the subclavian artery was performed. Selective angiography demonstrated tortuosity and mild stenosis seen in the proximal portion of the vessel. There is no pullback gradient. "*

Seeing this portion of the documentation made me jump to the 36215 code because the physician states that due to the patients peripheral artery disease selective engagement of the subclavian was performed.  Is this not correct and if so, can you please give us some reference material that states that?  We are still new to cardiology and are always looking for new reference material.


----------



## Misty Dawn (Oct 16, 2012)

CPCCODERII said:


> *"Of note, due to the patient's severe peripheral artery disease, selective engagement of
> the subclavian artery was performed. Selective angiography demonstrated tortuosity and mild stenosis seen in the proximal portion of the vessel. There is no pullback gradient. "*
> 
> Seeing this portion of the documentation made me jump to the 36215 code because the physician states that due to the patients peripheral artery disease selective engagement of the subclavian was performed.  Is this not correct and if so, can you please give us some reference material that states that?  We are still new to cardiology and are always looking for new reference material.



I understand what you are saying above but this is included in the work of 93459 to determine the viability of the IMA as a bypass graft.  Please see AMA article http://www.ama-assn.org/resources/doc/cpt/no-index/cpt-assistant-december-2011.pdf  page 11 under the 93459 heading. The bullets list what is included in 93459: catherization of the subclavin artery is listed as included.  hope that helps, Misty


----------

