# Lhc coronary and stent



## OPENSHAW (Feb 8, 2013)

We had a patient come in for the following procedure:

Left heart Catheterization
Selective Coronary Arteriograms
Percutaneous transluminal angioplasty of a very complex lesion of the left circumflex followed by stenting of the trunk of the left circumflex.

Indication of the procedure:  Patient with stress test that was abnormal and angina pectoris.  The patient has unstable angina and coronary artery disease.  

The patient originally was scheduled for a LHC BUT WE Wound UP STENTING.  

Op report states it was decided to proceed with coronary angioplasty as the patient had critical stenosis of the left circumflex.  There was 99% stenosis at the site of bifurcation at the origin of the 1st obtuse marginal.  There was also 60% stenosis of the trunk of the left circumflex.  The lesion was extremely complex, but because of the patient's age and overall condition, there was no choice but to proceed with percutaneous transluminal angioplasty in order to improve the overall status of the patient. 

Do I bill for CPT Code 92928-LC-22

AND can I bill for CPT Code 93458-26-59 due to the patient originally coming in for this procedure.

Help!  Thank you!


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## dpeoples (Feb 8, 2013)

OPENSHAW said:


> We had a patient come in for the following procedure:
> 
> Left heart Catheterization
> Selective Coronary Arteriograms
> ...



The general answer is yes you can. However, without a report I don't know if 93458 is accurate or not. Docs will call it a LHC but all they do sometimes is a coronary angiography (93454).

HTH


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## OPENSHAW (Feb 8, 2013)

The op report shows left heart cath as procedure #1, then procedure #2 shows selective coronary arteriograms.  Procedure #3 shows percutaneous transluminal angioplasty with stenting.

Description of procedure reads:  Under local anesthetic, utilizing 2% Xylocaine, the left femoral artery was cannualted and a 6-French sheath was introduced under pressure and fluoroscopy monitoring and left Judkins catheter was advanced to the ostium of the left coronary, where left coronary arteriograms were performed in multiple projections.  Catheter was then exchanged for an A1 modified wire that used to cannulate the right coronary artery in the left anterior oblique projection.

What do you think?  Can I bill for both codes and which ones would you use?  Can I use Modifier 22 as well?  Thanks.


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## dpeoples (Feb 8, 2013)

OPENSHAW said:


> The op report shows left heart cath as procedure #1, then procedure #2 shows selective coronary arteriograms.  Procedure #3 shows percutaneous transluminal angioplasty with stenting.
> 
> Description of procedure reads:  Under local anesthetic, utilizing 2% Xylocaine, the left femoral artery was cannualted and a 6-French sheath was introduced under pressure and fluoroscopy monitoring and left Judkins catheter was advanced to the ostium of the left coronary, where left coronary arteriograms were performed in multiple projections.  Catheter was then exchanged for an A1 modified wire that used to cannulate the right coronary artery in the left anterior oblique projection.
> 
> What do you think?  Can I bill for both codes and which ones would you use?  Can I use Modifier 22 as well?  Thanks.



Based on this, and the first post;
92928 LC
93454-26,59

Modifier 22 can be appended if you think it is warranted. These procedures are already complex, and I don't know if 22 will necessarily mean more $$. I would not. 

HTH


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## OPENSHAW (Feb 8, 2013)

Thank you!


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## OPENSHAW (Feb 20, 2013)

*Lhc and stent*

We had a patient come in for the following procedure:

Left heart Catheterization
Selective Coronary Arteriograms
Percutaneous transluminal angioplasty of a very complex lesion of the left circumflex followed by stenting of the trunk of the left circumflex.

Indication of the procedure: Patient with stress test that was abnormal and angina pectoris. The patient has unstable angina and coronary artery disease. 

The patient originally was scheduled for a LHC BUT WE Wound UP STENTING. 

Description of Procedure:  Under local anesthetic, utilizing 2% Xylocaine, the left femoral artery was cannulated and a 6-French sheath was introduced under pressure and fluoroscopy monitoring and left Judkins catheter was advanced to the ostium of the left coronary, where left coronary arteriograms were performed in multiple projections.  Catheter was then exchanged for an A1 modified wire that used to cannulate the right coronary artery in the left anterior oblique projection.

At this point, it was decided to proceed with coronary angioplasty as the patient had critical stenosis of the left circumflex. There was 99% stenosis at the site of bifurcation at the origin of the 1st obtuse marginal. There was also 60% stenosis of the trunk of the left circumflex. The lesion was extremely complex, but because of the patient's age and overall condition, there was no choice but to proceed with percutaneous transluminal angioplasty in order to improve the overall status of the patient. 

The patient was given Angiomax adjusted with his renal function in order to achieve anticoagulation,  An ACT was obtained prior to initiating the interventional procedure and it was in excess of 300.

Q4 guiding 6-French was introduced and carefully positioned on the ostium of the left coronary artery.  Two Choice floppy wires were then advanced, were crossing the lesion and advanced down to the proper circumflex and all the way down to the obtuse marginal.  A 2.5 x 12 trach balloon was carefully advanced through the lesion with great deal of difficulty.  The lesion was critical, was 99% and created great deal of resistance to the passage of the balloon.  It took a lot of manipulation in order to advance the balloon.  The wire had to be exchanged for a Prowater in order to obtain more stabilized wire and allow the balloon to cross the lesion.  Once this was achieved, the balloon was inflated to 6 and then 8 atmospheres until all the indentation and signs persistance of a blockage were resolved.  During this procedure, the patient experienced chest discomfort.

The balloon was then removed.  An angiogram was done and it was noted that there was still some haziness at the site of stenosis.  A stent, 2.5 x 12, was attempted to cross the lesion; however, despite performing multiple attempts, the stent would not advance beyong the origin of the lesion and had to be deployed at the site of the circumflex, where there was a 60% stenosis.  The stent was deployed at 12 atmospheres without difficulty.  An angiogram was done after the stent was deployed and it was noted that the lesion had improved.  The 99% stenosis had been reduced to approximately 50% to 60%, and at this point, due to difficulty of the amount that was performed, it was decided to abort further procedures and leave the patient with the anatomy as such.

The patient tolerated the procedure well.  There were no intraoperative complications.  The patient did not develop ST segment changes or hypotension during the procedure.  

The patient was sent to the unit in order to recover and have the sheaths removed.

Final diagnosis:  Critical stenosis of the left circumflex with associated 90% stenosis of the trunk of the circumflex.  The patient was treated with percutaneous transluminal angioplasty and deployment of a single stent.


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