# please help:atherectomy/angioplasty help



## bmkardok (Sep 28, 2010)

I have this note that I have coded but I feel as though I am missing something. I'd really appreciate if anyone could look at the note below and give me your opinion. The procedures are all performed percutaneously. I believe that there should be radiology services, but I haven't seen a note this difficult. I only get to code once the code is denied by an insurance company or if the office is having trouble.

Procedure: Selective left coronary angiogram.
Rotational atherectomy(rotablator 1.5mm bur) first marginal of circumflex.
Balloon angioplasty followed by placement of drug-eluting stent, Xience stent (2.5 x 18) proxdimal first marginal of circumflex.

Procedure: The patient was taken to the laboratory and after a time-out correctly identified the patient, procedure, and site, a 6-Frenc sheath was placed percutaneously in the right common femoral artery. Angiogram after sheath placement showed diffuse significant disease of at least 50-70% throughout the common femoral. Diagnostic left coronary angiography was performed with an XB 3.5 guide.

Diagnostic Findings: Left Main- Large and normal.

Left Anterior Descending: Extensive calcifications throughout the proximal and midportion of this vessel. It is medium caliber and has moderate 50% just after it's origin. The vessel distally is free of disease extending around the apex. There is a very small early-arising first diagonal, which is diffusely diseased and 90% in it's mid portion and very limited distribution.

Left Circumflex: The intermediate first marginal branch appears to be subtotally occluded with 99% or subtotal occlusion just shortly after it's origin. The distal vessel, previously seen to circumflex trunk originates after the origin of that first marginal and a small caliber calcified with moderate 50% narrowing. There is a very tiny second marginal branch (1mm caliber), which has 90%in it's proximal portion.

Based on these finding, she is a candidate for intervention on the severe diesase, which has significantly progressed in the first marginal branch of the circumflex.

Intervention Protocol: Anticoagulation: Intravenous heparin 5000 units given, ACT 258 seconds. After intervention, repeat ACT was drawn and was 228 towards the end of the case.

Guide catheter: XB 3.5.

Guidewire: Initially tried to pass the Rotowire floppy 14 carefully through the occluded segment, but that was unsuccessful as was an attempt with a BMW wire. That wire was exchanged using an over-the-wire balloon and the subtotal occlusion was successfully crossed wtih a Pilot Hi-Torque 50MS.

Pre-Rotablator dlation: Apex over-the-wire balloon advanced distal to the dilated area, the Pilot wire was exchanged for the Rotowire floppy.

Rotationl Atherectomy was then performed with a 1.5 mm bur with three passes at first 140,000 rpm 13 seconds; second pass 153,000 rpm 17 seconds;and third pass 153,000 rpm 18 seconds.

Rotational Atherectomy results: Marked improvement with approximately 2-mm lumen, smooth without edge dissection.

The Rotowire was exchanged for a BMW wire and repeat balloon dilations, post atherectomy performed first with an Apex 2.0 x 12 mm length, 8 atmospheres throughout the diseased segment followed by Voyager RX 2.5 x 15mm to 6 atmospheres.

Intracoronary nitroglycerin 100 mcg was given and angiofram confirmed a patent vessel without edge dissection.

The proximal portion of this medium caliber diffusely diseased marginal was then stented with a Xience V RX DES stent 2.5x 18 deployed at 14 atmospheres for 25 seconds carefully positioned so that it was st the very origin of the vessel, but not extending into the left main.

Final Angiogram: The proximal area shows a widely restored lumen without residual narrowing. There is no edge dissection proximal or distal and no evidence of vessel occlusion distally to suggest any distal embolization. The mid portion is smaller caliber (2mm or less) with diffuse irregularities of the junction of the mid and distal portion of this long distribution vessel, there is moderate eccentric "hazy" lesion of 50%, which does not appear flow limiting.

Total Contrast: Not recorded.

Fluoro Time: 20 minutes

Overall Impression: Successful rotational atherectomy (Rotablator) followed by drug-eluting stent (Xience 2.5 x 18) stenting of proximal first marginal of circumflex.

92995/LD
92996/LC59
93545

Thank you in advance for your help.


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## armymomryan (Sep 28, 2010)

93545 is for the injection portion only, you will need to add 93556-26 for the imaging portion, 

I am a little confuse about the stents, I would normally code 92980-51-LC for the stent but the CCI edit does not allow it with 92995, although in the CPT book after code 92996 it does say  (for stent placement following completeion of angioplasty or atherectomy, see 92980,92981)

Anyone else have any thoughts on the stent coding?


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## Jess1125 (Sep 28, 2010)

This is what I see:

93508-26
93545
93556-26.59

Above codes for the coronary angiography that was done prior to the intervention as this was a diagnostic study as dictation states based on the above patient was candidate for intervention.

92980.LC for the stent placement to circumflex.

This is the only intervention that will be coded as everything that was done was part of the left circumflex and you will only able to bill for the highest valued intervention and that will be a stent. (Atherectomy, PTCA will be included in above since this was all done in circumflex vessel.

Jessica CPC, CCC


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## KeriH423 (Sep 28, 2010)

I agree with Jess1125.  

Interventional Hierarchy for PCI is as follows:

1) Drug-eluting stent
2) Bare metal stent
3) Atherectomy
4) Angioplasty

Keri H., CIRCC


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## bmkardok (Sep 28, 2010)

Thank you all so much. I know it was a long note. Have a great day!!!


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