# LHC and Stents



## nancy.anselmo@ccrheart.com (Feb 27, 2013)

Again I am confused on what codes and modifiers are to be used for this patient any help is greatly appreciated
INDICATION: Acute myocardial infarction, congestive heart failure, ventricular
arrhythmia and sudden death.

HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old gentleman who
presented with heart failure and rapid atrial fibrillation, subsequent flash
pulmonary edema and VF arrest with acute ST elevation and myocardial infarction
with subsequent angiography and stenting of his left circumflex system. He was
found to have residual disease in his right coronary system that was quite
extensive with a large dominant system. He had renal insufficiency and
therefore he was temporized and he remained intubated and presents today for a
staged angioplasty.

Informed consent was obtained. The patient's daughter offered consent on the
patient's behalf. Risks and benefits were explained. The right radial artery
was exposed and prepped in the usual sterile fashion and 2% Lidocaine was
infused subcutaneously. A 6 French diagnostic JR4 catheter was used for left
heart catheterization revealing a left ventricular end-diastolic pressure
severely elevated at 35 mmHg. Subsequently, a JR4 guide catheter was used for
selective coronary angiography of the right coronary system. This revealed a
70% proximal stenosis and 80% mid vessel stenosis. An 80% ostial RPDA with a
90% mid RPDA stenosis and 90% RPL and subsequent 80% RPL stenosis as well.
Angiomax was used for vent-to-vent anticoagulation and run through wire was
placed to both distal RPL and RPDA. A 2.5/15 balloon was used to predilate
multiple lesions.

Attention was then first drawn to the RPL system. A 2.5 x 26 Resolute was then
deployed at 14 atmospheres with an excellent angiographic result. Attention was
then drawn to the RPDA lesions. A 2.5 x 18 Resolute was deployed in the mid
vessel segment. A 2.75 x 22 Resolute was deployed across the ostium into the
proximal segment of the right posterior descending artery.

Next, a 3.5 x 12 Resolute was deployed in the mid RCA and a 4.0 x 18 Resolute
was deployed to the proximal RCA. TIMI-3 flow was achieved with an excellent
angiographic result.

SUMMARY: Complex percutaneous intervention of multiple sequential lesions in
the right posterior descending artery as well as the right posterolateral
system. Elevated left ventricular end-diastolic pressure.

CLINICAL PATHWAY: The patient will be maintained on aspirin, Plavix and
Coumadin for not only his coronary disease but his atrial fibrillation. He will
likely require further diuresis as he remains intubated with severely elevated
left ventricular end-diastolic pressures. He has renal insufficiency and this
will be monitored. He received N-Acetylcysteine prior to the procedure. Will
recommend monitoring for renal dysfunction. The patient has been persistently
bradycardic, however, maintain hemodynamics. We will hold his beta-blocker in
light of this.


I have  93458-26-59
92928-RC
now here is where we are confused
92929-
92929-
Thank you Nancy


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## dpeoples (Feb 27, 2013)

nancy.anselmo@ccrheart.com said:


> Again I am confused on what codes and modifiers are to be used for this patient any help is greatly appreciated
> INDICATION: Acute myocardial infarction, congestive heart failure, ventricular
> arrhythmia and sudden death.
> 
> ...



RC should be appended to the 92929(s), and you may need a 76 or 59 on the second, depending on payor preference.

HTH


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## nancy.anselmo@ccrheart.com (Feb 27, 2013)

The payer is Medicare, so I put RC on all the stents?


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## dpeoples (Feb 27, 2013)

nancy.anselmo@ccrheart.com said:


> The payer is Medicare, so I put RC on all the stents?



That is my understanding. Also, it seems that I have read that payment for branches is bundled into the primary branch treatment anyway.

HTH


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## TWinsor (Feb 28, 2013)

If the PCI is a staged procedure as your note states it is not appropriate to bill another LHC.


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