# Help coding! R & L Cath with Peripheral procedure



## jlb102780 (Dec 23, 2009)

Hi everyone! Here's another really long report that I'm stuck on. Any help coding this would be so wonderful 




NAME OF TEST:                                                                 
   1. Left and right heart cardiac catheterization.                           
   2. Coronary angiography.                                                   
   3. Left ventriculography.                                                  
   4. Abdominal aortogram.                                                    
   5. PTA of the right external iliac artery.                                 
   6. Implantation of a 8 mm (16 mm long) Absolute self expanding peripheral  
       stent in the very distal aspect of the right common iliac artery       
       extending down almost the entire length of the right external iliac    
       artery.                                                                

HISTORY                                                                       
The patient is a very unfortunate, 41-year-old female who has end stage renal 
disease.  She developed bacterial endocarditis in the past year or so up in   
Virginia.  She was treated for this.  She had severe mitral regurgitation.    
She was treated with a prolonged course apparently of antibiotics and was     
treated medically.  She has begun to experience symptoms of dyspnea.  She had 
an echocardiogram with Doppler study and was found to have severe mitral      
regurgitation.  There was concerns about a catheter infection as well.  The   
patient was discharged home from Baptist Medical Center and came back with    
acute pulmonary edema.  After careful discussion of the various options, she  
was referred for a right and left heart cardiac catheterization.              

PROCEDURE                                                                     
The patient was brought to the cardiac catheterization laboratory in very     
stable condition.  Both groins were carefully prepped and draped in the usual 
sterile fashion.  She was found to have very poor pulses in both groins.  We  
elected to use the right side.  The patient was anesthetized using 1%         
Xylocaine.  She was also given some intravenous sedation.  Please see the     
accompanying nursing data sheet for full details regarding her sedation.  I   
was able to easily cannulate the right femoral vein without significant       
difficulty.  A 7 French venous sheath was then inserted in the right femoral  
vein.  We then had a great deal of difficulty trying to cannulate the right   
femoral artery.  The pulse was very poor.  I decided to proceed on with the   
right heart cardiac catheterization.  We advanced the 7 French Swan-Ganz      
catheter up over a J wire and manipulated the catheter out into the patient's 
left pulmonary artery.  A pulmonary pressure was obtained as well as a        
pulmonary capillary wedge pressure.  The catheter was then pulled back into   
the patient's right ventricle after obtaining an arterial saturation          
measurement within the left pulmonary artery.  A right ventricular pressure   
was then obtained.  A right atrial pressure was obtained as well.  The        
pigtail catheter was then removed.                                            

After some more difficulty, I was able to successfully cannulate the          
patient's right femoral artery.  A J tip wire was manipulated after some mild 
difficulty up the patient's right femoral artery subsequently into the right  
iliac artery up into the aorta.  The wire was clearly in the aorta distally.  
I advanced a 5 French sheath carefully up the patient's right femoral artery  
over the J wire.  We then advanced a 5 French 4 left Judkins coronary         
diagnostic catheter.  All subsequent wire exchanges were performed over an    
exchange wire.  Diagnostic coronary angiography was then performed utilizing  
a 5 French 4 left Judkins and a 5 French 4 right Judkins coronary diagnostic  
catheter in order to inject the left and right coronary arteries,             
respectively.  A left ventriculogram was then performed in the 30 degree RAO  
projection utilizing a 6 French angled pigtail catheter.  This angled pigtail 
catheter was then pulled back across the aortic valve.  It should be noted    
that upon obtaining the arterial access, we did measure the arterial          
saturation measurement in the patient's aorta.  She was noted to have room    
air oxygen saturation of 90%.                                                 

The patient was noted to have severe mitral regurgitation as expected.  Left  
ventricular systolic function,  however, was somewhat decreased and the       
ejection fraction was only approximately 50%.  In addition, we obtained a net 
for cardiac output by the FICK method of 2.7 liters per minute.  I felt that  
the patient might need to have an intraaortic balloon pump placed in order to 
get through cardiac surgery eventually.  I felt that it would be helpful to   
perform an abdominal aortogram in order to assess the patient's abdominal     
aorta as well as her iliac arteries.  She did have stents in both iliac       
arteries.  These were self expanding stents that were easily visualized under 
fluoroscopy.                                                                  

I initially performed an abdominal aortogram with the pigtail catheter being  
placed at the level of the first lumbar vertebrae.  I was able to visualize   
the patient's abdominal aorta.  She did have some narrowing in the abdominal  
aorta but the vessel was patent.                                              

We then pulled the pigtail catheter down until it was located just above the  
aortic bifurcation.  A second abdominal aortogram was performed to look at    
the iliac and femoral arteries.  On the left side, the patient was noted to   
have a stent in her left iliac artery that was widely patent.  She did have   
some narrowing in her left external iliac artery.  This vessel was patent.    
Her right external iliac artery, however, with the catheter passing across it 
appeared to be essentially totally occluded after the takeoff of the right    
internal iliac artery.  I removed the catheter and pulled the sheath back     
slightly with the J wire up well into the patient's abdominal aorta.  The     
injection was performed through the sheath and the patient was noted to have  
essentially a subtotally occluded right external iliac artery almost along    
its entire length.                                                            

At this point, I felt that we needed to perform some type of catheter based   
intervention to try to obtain patency of the right external iliac artery.  I  
felt that if I did not do this that when I pulled the J wire back the patient 
could develop an ischemic right leg.  I felt this was essentially an          
emergency.  In addition, I also felt that the patient may need to have an     
intraaortic balloon pump and achieve an access for this.  I therefore         
performed an additional cineangiogram through the sheath in the 30 degree LAO 
projection.  This laid out the takeoff of the right external iliac artery     
very nicely.  I then selected a 5 mm peripheral balloon catheter, the balloon 
being 40 mm in length.  A total of three balloon inflations were made with    
this catheter.  We then deflated the balloon catheter and removed it.         
Subsequent cineangiograms revealed a significant improvement at the PTCA      
site.  I then selected a 6 mm peripheral balloon catheter with the balloon    
being 40 mm in length.  Three balloon inflations were made with this          
catheter.  We then deflated the balloon catheter and removed it.  Subsequent  
cineangiograms revealed a much more widely patent right external iliac artery 
now.  There was one area, however, at the takeoff of the right external iliac 
artery where the artery was still very tightly narrowed.  I felt that we      
needed to place a self expanding stent and would have to place the most       
distal part of the stent up into the distal aspect of the patient's right     
common iliac artery.  I therefore selected an 8 mm Absolute self expanding    
stent with the stent being 60 mm in length.  I brought this stent down to     
what I felt was then most optimal position.  When we had it in this position, 
we removed the deployment sheath.  The stent appeared to expand very nicely.  

I then postdilated the stent with a 6 mm Agile Track balloon catheter we      
utilized earlier.  Two balloon inflations were made within the stent.         

We then deflated the balloon catheter and removed it.  The right iliac artery 
and right external iliac artery were now widely patent.  There was excellent  
flow up the vessel.  We could see runoff into the contralateral iliac artery  
as well.  In addition, the patient now had a normal pressure wave form        
tracing at the sheath insertion site in the right femoral artery.             

The patient tolerated the procedure quite well.  There were no complications. 
She was taken to the cardiac catheterization laboratory holding area in order 
to have her sheaths pulled.                                                   

RESULTS                                                                       

HEMODYNAMICS                                                                  
   1. Mean right atrial pressure is 17.                                       
   2. Right ventricle pressure is 65/13.                                      
   3. Mean pulmonary artery pressure is 65/27 with a mean of 42.              
   4. Mean pulmonary artery capillary wedge pressure is 29 with a V wave      
       equal to 50.                                                           
   5. Left ventricular pressure is 87/21.                                     
   6. Aortic pressure 94/77 with a mean of 85.                                
   7. Oxygen saturation:  Aorta 90%, pulmonary artery 42%, cardiac output     
       FICK 2.7 liters per minute.                                            

FEMORAL ARTERY PRESSURES                                                      
   1. Prior to stent placement the right femoral artery is 59/54 with a mean  
       of 57.                                                                 
   2. After stent placement right femoral artery 106/72 with a mean of 84.    

ANGIOGRAPHY                                                                   
   1. The left main coronary artery is normal.                                
   2. The left anterior descending coronary artery is normal.                 
   3. The left circumflex coronary artery is normal.                          
   4. The right coronary artery is a large and dominant vessel which is       
       normal.                                                                
   5. Left ventriculogram reveals a dilated left ventricle.  Left ventricular 
       systolic function is somewhat reduced and the overall left ventricular 
       ejection fraction was estimated to be approximately 50%.  There was    
       severe mitral regurgitation detected.  The left atrium is markedly     
       dilated.                                                               
   6. Abdominal aortogram reveals an unremarkable abdominal aorta.  The right 
       common iliac artery has a stent present which is patent.  The right    
       external iliac artery is subtotally occluded at its takeoff.  The left 
       common iliac artery has stents present that are widely patent.  There  
       is some mild narrowing noted within the stent.  The left external      
       iliac artery has a 40 to 50% obstructive narrowing noted within it.    
   7. After successful PTA and subsequent implantation of an 8 mm (16 mm      
       long) Absolute self expanding stent into the distal right common iliac 
       artery extending along the entire length of the right external iliac   
       artery, the subtotally occluded right external iliac artery            
       preintervention was reduced to no residual narrowing postintervention. 
       There is excellent flow in the distal vessel.  There is no dissection. 

CONCLUSION                                                                    
   1. Marked pulmonary hypertension secondary to elevated pulmonary capillary 
       wedge pressure secondary to severe mitral regurgitation.               
   2. Reduced cardiac output secondary to severe mitral regurgitation.        
   3. Dilated left ventricle with reduced left ventricular systolic function. 
   4. Markedly dilated left atrium.                                           
   5. Angiographically normal coronary arteries.                              
   6. Abdominal aortogram revealing widely patent stents in both common iliac 
       arteries bilaterally with the right external iliac artery being        
       subtotally occluded.                                                   
   7. Successful PTA with subsequent implantation of an 8 mm (16 mm long)     
       Absolute self expanding peripheral stent in the very distal aspect of  
       the right common iliac artery extending almost the entire length of    
       the right external iliac artery.  The subtotally occluded right        
       external iliac artery preintervention was reduced to no residual       
       narrowing postintervention.  There was excellent flow in the distal    
       vessel.  There was no evidence of dissection.


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## dpeoples (Dec 23, 2009)

jlb102780 said:


> Hi everyone! Here's another really long report that I'm stuck on. Any help coding this would be so wonderful
> 
> 
> 
> ...



quite an extensive procedure...here goes:
part 1
93526(26) includes all catheter placements
93556(26)
93555(26)
93545
93543

part 2
37205/75960(26)
35473/75962 suboptimal results are documented allowing for stent and plasty.
75625(26,59) medical necessity is documented allowing for aortogram w/heart cath.
75716(26,59) medical necessity is documented...

Ordinarily the aortogram and extremity angiogram would be included (IMO)with the heart cath but with a separately documented medical reason, and a thorough interpretation of these, they are allowed.

Also, clear documentation of suboptimal results of the iliac angioplasty allow for both interventional procedures to be billed.

HTH


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## jlb102780 (Dec 23, 2009)

Thank you sooooo much Danny!


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