# Need quick help with cath/ptca



## Jane5711 (Oct 10, 2016)

Hi Can anyone help me with coding this?

PROCEDURES PERFORMED:                                                          
1.  Left heart cardiac catheterization.                                        
2.  Selective coronary artery angiography.                                     
3.  Left ventriculography.                                                     
4.  Right heart cardiac catheterization.                                       
5.  Selective bilateral renal artery angiography.                              
6.  CSI orbital atherectomy of the mid left anterior descending artery.        
7.  Angioplasty and stent of the mid left anterior descending artery using a   
    3.0/18 mm Xience Alpine Everolimus drug-eluting stent, post-dilated with   
    a 3.25 mm balloon.                                                         
8.  Percutaneous transluminal coronary angioplasty and stent of the mid left   
    circumflex artery using a 2.5/15 mm Xience Alpine Everolimus               
    drug-eluting stent.                                                        
9.  Percutaneous transluminal coronary angioplasty and stenting of the         
    ostial proximal portion of the third diagonal branch with a 2.25/12 mm     
    Xience Alpine Everolimus drug-eluting stent.                               

INDICATIONS:                                                                   
1.  Multi-vessel coronary artery disease with anterior wall ischemia and       
    inferior wall ischemia.                                                    
2.  Symptoms of dyspnea and fatigue.                                           
3.  Mitral valve regurgitation.                                                
4.  Hypertension, hypertensive heart disease, and renal artery                 
    atherosclerosis.                                                           
5.  Mitral valve regurgitation with cardiomyopathy and dyspnea and fatigue     
    symptoms.                                                                  

DESCRIPTION OF PROCEDURE: After the informed consent was obtained, the         
patient was prepped and draped in the usual sterile fashion. Lidocaine 2       
percent was used for local anesthesia in the right groin. Vascular access      
was obtained in the right femoral artery and right femoral vein. Over a        
guidewire, a 7-French angiographic sheath was placed in the right femoral      
vein and a 6-French angiographic sheath was placed in the right femoral        
artery.                                                                        

A 6-French TD Swan-Ganz catheter was introduced through the right femoral      

vein into the pulmonary artery and right heart cardiac catheterization was     
performed in a routine fashion.                                                

A 6-French pigtail catheter was introduced over a guidewire into the left      
ventricle. Left ventricular hemodynamics was measured and left                 
ventriculography in the RAO projection was performed. The pigtail catheter     
was removed under hemodynamic monitoring from the left ventricle to the        
aorta.                                                                         

Then, a 6-French JL4 catheter was introduced over a guidewire selectively      
engaging the left coronary artery and selective left coronary artery           
angiography was performed.                                                     

Over a guidewire, a 6-French JL4 catheter was introduced selectively over      
the right coronary artery and selective right coronary artery angiography      
was performed.                                                                 

A 6-French JR4 catheter was then used to selectively engage the left renal     
artery and selective left renal artery angiography was performed.              

A 6-French JR4 catheter was then used to selectively engage the right renal    
artery and selective right renal artery angiography was performed.             

At the end of the diagnostic cardiac catheterization, the guidewire and        
diagnostic catheters were removed. Then, the CSI orbital atherectomy of the    
mid LAD was performed, following which, angioplasty and stent of the mid LAD   
followed, which angioplasty and stent of the ostial proximal portion of the    
diagonal branch and then angioplasty and stent of the mid left circumflex      
arteries were performed. At the end of the angioplasty and stent of the        
procedure, the guidewire and diagnostic catheters were removed. Arterial       
sheath and venous sheaths were sutured in place and the patient was            
transferred in a stable condition to the floor for further care with no        
complications.                                                                 

HEMODYNAMIC DATA:                                                              
1.  Pulmonary capillary wedge pressure, 19/19/11 mm.                           
2.  Pulmonary artery 20/6/12 mm.                                               
3.  Right ventricle 22/2/5 mm.                                                 
4.  Right atrium 3/5/2 mm.                                                     
5.  Left ventricle 193/2/70 mm.                                                
6.  Aorta 172/64/76 mm.                                                        
7.  Follow oxygen saturation; pulmonary artery 78 percent, aorta 100           
    percent, and right atrium 78 percent.                                      

VASCULAR RESISTANCE:                                                           
1.  Pulmonary vascular resistance 11.                                          
2.  Total pulmonary vascular resistance 131.                                   
3.  Systemic vascular resistance 1047.                                         



CARDIAC OUTPUT:                                                                
1.  Cardiac output by Fick method, 7.37 liters per minute, cardiac index is    
    3.76 liters per minute mL/m2.                                              
2.  Cardiac output by thermodilution technique 5.57 liters per minute,         
    cardiac index is 2.86 liters per minute m2.                                

ANATOMIC DATA:                                                                 
LEFT VENTRICULOGRAPHY:                                                         
1.  Anterobasal normal.                                                        
2.  Anterolateral mild-to-moderate hypokinesis.                                
3.  Anteroapical moderate hypokinesis.                                         
4.  Distally inferior apical mid hypokinesis.                                  
5.  Posterobasal normal.                                                       
6.  Mid inferior normal.                                                       
7.  Left ventricular ejection fraction is approximately 45-50 percent visual   
    estimate with two plus mitral insufficiency noted and mild gradient        
    across the aortic valve noted.                                             

CORONARY DATA:                                                                 
1.  Calcification noted fluoroscopically in the proximal and mid left          
    anterior descending artery, proximal left circumflex artery, and           
    proximal mid right coronary artery.                                        
2.  LEFT MAIN CORONARY ARTERY: The left main coronary artery has no            
    high-grade focal stenosis. There is mild plaquing in its distal portion;   
    it bifurcates into left anterior descending artery and left circumflex     
    arteries.                                                                  
3.  LEFT ANTERIOR DESCENDING ARTERY: The left anterior descending artery has   
    mild disease in its proximal portion.                                      

There are 3 diagonal branches. The proximal LAD has a smooth 20 percent        
narrowing up to the origin of the first diagonal branch.                       

The first diagonal branch is a small-to-medium caliber vessel with mild        
disease.                                                                       

The second diagonal branch arises close to it with an ostial of 40 percent     
stenosis.                                                                      

The second diagonal branch is also a small-to-medium caliber vessel with       
mild disease.                                                                  

The third diagonal branch is a medium caliber vessel with ostial 60 percent    
stenosis.                                                                      

The mid left anterior descending artery involving the origin of the first to   
third diagonal branch and just distal to this has a lesion with up to 80       
percent stenosis just distal to the origin of the third diagonal branch and    
a 40-50 percent stenosis between the first and third diagonal branches.        




Mid LAD beyond this has mild disease. It is transapical. Distal LAD has mild   
disease. It is a transapical vessel according to round the apex.               

4.  LEFT CIRCUMFLEX ARTERY: The left circumflex artery has mild disease in     
    its proximal portion with calcification and 30 percent stenosis in its     
    proximal portions. It gives rise to a medium-caliber first obtuse          
    marginal branch.                                                           

Mid left circumflex artery has 30-40 percent stenosis with a hazy stenosis     
in the mid portion.                                                            

It gives rise to AV circumflex artery beyond the origin of the AV circumflex   
artery. The mid circumflex artery has 80 percent hazy stenosis as it           
bifurcates into second and third obtuse marginal branches. Both second and     
third obtuse marginal branches are small-to-medium caliber vessel with mild    
disease.                                                                       

5.  Right coronary artery: The right coronary artery is a dominant vessel.     
    Mild-to-moderate calcification noted in the proximal to mid right          
    coronary artery.                                                           

There is a 40 percent stenosis of the proximal right coronary artery           
followed by another 40 percent stenosis in the midportion of the right         
coronary artery and mild ectasia just distal to this.                          

Mid right coronary artery at the second bend has an eccentric 75 percent       
stenosis. Distal to this right coronary artery is a mild diffuse disease. It   
is a medium caliber vessel.                                                    

Distally it bifurcates into the posterolateral branch, which is a medium       
caliber vessel with moderate disease distally and 3 posterolateral branches,   
which have mild-to-moderate diffuse disease.                                   

6.  LEFT RENAL ARTERY: The left renal artery has mild disease with a 30        
    percent stenosis in the midportion.                                        

7.  RIGHT RENAL ARTERY: The right renal artery has mild disease without any    
    high-grade focal stenosis.                                                 

IMPRESSION:                                                                    
1.  Mild-to-moderate decreased left ventricular systolic function with         
    mild-to-moderate anterolateral and moderate anteroapical hypokinesis       
    with LVEF in the range of 45 percent with 2 plus mitral insufficiency.     
    Mild gradient across the aortic valve with near normal pulmonic arterial   
    wedge pressure and normal pulmonary arterial pressures.                    
2.  Severe 3-vessel coronary artery disease with calcific 80 percent           
    stenosis of the mid LAD just beyond the origin of the diagonal branch;     
    50 percent stenosis of the ostial portion of the third diagonal branch;    
    80 percent stenosis of mid left circumflex artery just prior to its        



    bifurcation into the 2 obtuse marginal branches; 75 percent stenosis       
    with calcification of the mid right coronary artery.                       
3.  Patent renal arteries bilaterally with mild disease.                       

RECOMMENDATIONS:                                                               
1.  The patient has anteroapical and inferior wall ischemia, but there was     
    also significant lesion in the left circumflex artery.                     
2.  Recommend further invasive interventional treatment with atherectomy       
    followed by angioplasty of the LAD and angioplasty of the diagonal         
    branch with stenting as needed as well as angioplasty of the mid left      
    circumflex artery. Consider elective atherectomy and angioplasty of the    
    right coronary artery in the future as a staged procedure.                 
3.  _____ coronary artery disease.           

What I come up with is 92928 LD, 92929, LC AND 36252.  I'm just checking to make sure I have all the stents and angioplastys.   Any help will do.  Thanks


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## Jane5711 (Oct 11, 2016)

*ANY ONE? Jim?*

Anyone?  Jim?


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## merjim_m@yahoo.com (Oct 11, 2016)

Jane5711 said:


> Hi Can anyone help me with coding this?
> 
> PROCEDURES PERFORMED:
> 1.  Left heart cardiac catheterization.
> ...




Hello,

You might consider these codes,  diagnostic LT/RT cath. 93460-59, 36252, 92933-LD, 92929-LD, 92928-59-LC. I coded 92933, it said that the orbital atherectomy of the mid LAD was performed, then followed by stent and angioplasty, stent and angioplasty on 3rd diagonal branch, then stent and angioplasty on LC. Also since, they are utilizing DES, i think codes C9600-C9608 should be used instead of the 9 series.


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## Jane5711 (Oct 12, 2016)

Thank you.


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