# Stenting of the subclavian; please help



## willnat2 (Jul 28, 2011)

Here is the other procedure that I am having trouble with.

Status post coronary artery bypass graft surgery done 2 montsh ago, utilizing the left internal mammary to the LAD, right internal mammary to the right and obtuse marginal. The patient had recurrent episodes of substernal chest discomfort.

Procedures Performed:
Left heart catheterization
Left ventriculogram
Left internal mammary angiography
Right subclavian angiography
Right internal mammary angiography
Stenting of the right subclavian
Stenting of the proximal right internal mammary

The patient was brought to the cardiac catherization lab. The patient was cleaned and draped in a sterile fashion. A sheath was then introduced into either the femoral and brachial artery as appropriate and catheters were then placed to the heart to do diagnostic angiography of the coronary arteries.

The patient had right heart catheterization. A Swan-Ganz catheter was then placed into the right ventricular wedge position.

At the end of the procedure, all sheaths were removed and pressure was held. The patient was returned to the room in satisfactory condition.

Hemodynamic Results: Aortic pressure 166/69

Catheters used: A 6-French JL-4. 6-French JR-4.

Coronary Angiography: The left main coronary artery is widely patent, free of disease.

The LAD is occluded mid vessel after takeoff of a large first diagonal. First diagonal has minimal luminal irregularity ostaially, the remainder of the vesses is free of disease.

The circumflex artery shows diffuse disease of 30% proximal mid. There is also a first marginal, which is normal. Second marginal with a 95% lesion, which appears to be grafted distally. 

The right coronary artery is occluded proximally.

Left internal mammary is patent to the LAD. The       looks good and the LAD fills in the antegrade direction, free of disease.

The right subclavian artery was cannulated. It showed and 80% to 90% two tandem lesions in the proximal portion of the right subclavian prior to the takeoff of the right internal mammary. 

The right internal mammary after intervention of the right subclavian was visualized, which shoed an ostial diesease of 90%. The remainder of that graft appears to be patent as it goes down to both the PDA and the obtuse marginal.

We then elected intervention of the right subclavian artery. Usisng and 8 French JR-4 guide with and 0.035 wire. Int primary fashion, we placed an 8.0 x 28 stent, which was able to cross bothe lesions. Inflated at 12 atmospheres with an excellent result. The 90% lesion down to less than 10% with TIMI grade 3 flow throughout the right subclavian vessel. 

We went to the LAO cranial. We then noterd a 90% lesion at the takeoff of the right internal mammary. The right internal mammary was then visualized as it went down to both the posterior descending artery and obtuse margianl as it was a Y graft distally, and both apperared to be patent. 

We then elected intervention of the proximal portion of the right internal mammary. We previously had given heparin, as well as intracoronary nitroglycerin to make spasm was not occurring, and it was not.

We then placed on .014 Graphix wire down into the the right internal mammary, and over that place 3.0 x 8 Taxus stent at the ostium of the right internal mammary, taking it 12 atmospheres in the body of the stent, 18 atmospheres at the ostium with an excellent result. The 90% lesion down to 0% residual with TIMI grade 3 flow. 

Impression:
Successful stenting of right subclavian artery with tow tandem 90% lesions down to less than 10% with an 8.0 s 28 stent.
Stenting of the right internal mammary artery proximally with a 90% lesion down to 0% with a 3.0 x 8 Taxus stent.
Patency of the left internal mammary artery to the left anterior descending.
Patency of the other coronary arteries as described above.
Mild hypertension.


Any help would be greatly appreciated.
Thanks,
Leslie


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## dpeoples (Jul 29, 2011)

willnat2 said:


> Here is the other procedure that I am having trouble with.
> 
> Status post coronary artery bypass graft surgery done 2 montsh ago, utilizing the left internal mammary to the LAD, right internal mammary to the right and obtuse marginal. The patient had recurrent episodes of substernal chest discomfort.
> 
> ...



I see:
92980 LC (RIMA to Obtuse Marginal)
93455. (coronaries and grafts, no LV or Right side pressures recorded)
swan ganz placed, but not for pressures also, included with 93455
37205-59/75960-(26)59 for Rt Subclavian Stent

all catheter placements are included.

HTH


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## willnat2 (Jul 31, 2011)

Danny,
Thanks so much for all of the help. I have a couple more questions. How did you know the subclavian stent was 37205? I saw this code, but couldn't find anywhere where it said subclavian. Do you know of someplace where I can find more information on this to help me? I see the 92980 LC. I did have a question about the 93459. I know the doctor wrote procedures performed were LHC with LV and Lima, but I don't see in the report about the LV. Also I see in the report a RHC was performed. It says, "The patient had right heart catheterization. A Swan-Ganz catheter was then placed into the right ventricular wedge position." The lady that retired told me that whenever it said Swan-Ganz it meant a right heart cath was done. Is this true? So would I use 93457? I'm not sure. If you could tell me some more resourses I could use I would really appreciate it. I am using Expert CPT code book and Cardiology/Cardiothoraic Surgery/vascular Sugery. 
Thanks again,
Leslie


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## dpeoples (Aug 5, 2011)

willnat2 said:


> Danny,
> Thanks so much for all of the help. I have a couple more questions. How did you know the subclavian stent was 37205? I saw this code, but couldn't find anywhere where it said subclavian. Do you know of someplace where I can find more information on this to help me? I see the 92980 LC. I did have a question about the 93459. I know the doctor wrote procedures performed were LHC with LV and Lima, but I don't see in the report about the LV. Also I see in the report a RHC was performed. It says, "The patient had right heart catheterization. A Swan-Ganz catheter was then placed into the right ventricular wedge position." The lady that retired told me that whenever it said Swan-Ganz it meant a right heart cath was done. Is this true? So would I use 93457? I'm not sure. If you could tell me some more resourses I could use I would really appreciate it. I am using Expert CPT code book and Cardiology/Cardiothoraic Surgery/vascular Sugery.
> Thanks again,
> Leslie



37205 is for any intravascular stent except those vessels excluded in the description of the code. I disagree that placing a Swan-Ganz means a RHC was done. IMO, a RHC requires measurement of blood gases and cardiac output/pressures (not documented here) and for that matter a LHC aslo has that minimum requirement (also not documented), I have therefore edited my original post. To be honest, I think the provider should revise the document to include cardiac output, which would prompt a change to 93457 and omission of 93503 because that would be the logical scenario.

Sorry to ramble. Long report=long questions=long response.

The swan-ganz, it is included with 93455, do not code. (I was just able to check the cci edits through encoder)

HTH


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## theresa.dix@tennova.com (Aug 8, 2011)

dpeoples said:


> 37205 is for any intravascular stent except those vessels excluded in the description of the code. I disagree that placing a Swan-Ganz means a RHC was done. IMO, a RHC requires measurement of blood gases and cardiac output/pressures (not documented here) and for that matter a LHC aslo has that minimum requirement (also not documented), I have therefore edited my original post. To be honest, I think the provider should revise the document to include cardiac output, which would prompt a change to 93457 and omission of 93503 because that would be the logical scenario.
> 
> Sorry to ramble. Long report=long questions=long response.
> 
> ...



I agree with Danny on this one! I do not see the documentation required to code the RHC. This doesnt seem to be a LHC because there isnt documentation that the aortic valve was crossed. The only pressures I see measured are of the aortic valve. I think there is enough documentation to use 93455. Unless the physician wants to do an addendum. Documentation is very important.


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