# Multiple access sites during cardiac cath



## 10marty (Mar 22, 2011)

One of my physicians did a cardiac cath and started in the radial artery.  In order to complete the cath he had to use the right femoral artery.  Would you bill the additional site?  If so which code would you use?  

MJ


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## theresa.dix@tennova.com (Mar 23, 2011)

10marty said:


> One of my physicians did a cardiac cath and started in the radial artery.  In order to complete the cath he had to use the right femoral artery.  Would you bill the additional site?  If so which code would you use?
> 
> MJ



Marty,

Why did he change vessels?


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## dpeoples (Mar 23, 2011)

10marty said:


> One of my physicians did a cardiac cath and started in the radial artery.  In order to complete the cath he had to use the right femoral artery.  Would you bill the additional site?  If so which code would you use?
> 
> MJ



When coding components (Interventional Radiology) this can make a huge difference, but in cardiac cath coding, not so much. I would need to see the actual report to be sure but you should have only a heart cath code (ie 93458) and perhaps an intervention (ie 92980), the number of access sites would not be a factor.

HTH


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## 10marty (Mar 23, 2011)

Danny, Theresa,

Thru the right radial artery he engaged the right coronary artery.  The catheterwas exchanged and multiple attempts were made to engage the left main, but proved to be unsuccessful thru the radial approach.  After 15-20 minutes I decided to to exchange to the right femoral artery and a #6 french sheath was introduced and secured in place.  The radial sheath was removed at that time and radial band placed with good hemostasis.  We started with a JL 3.5 diagnostic catheter, the left main inttubated and imaged..  We exchanged to pigtail in the LV gram was obtained.

Intervention:
After starting the patient on angiomax antithrombolytic medication a JR-4 catheter inserted in the r coronary intubated. Stents palced in the proximal RCA and 2 placed in the posterolateral branch.  After removing the balloon a couple pictures were taken after IC nitroglycerin.  Timi flow was 3 but after the wire was removed TIMI flow went to 2, attempted to re-engage, was unsuccessful and a proximal RCA dissection was noticed and dissected all the way back to the the ostium of the RCA and could not re-establish the wire thru the distal RCA.

Patients blood pressure dropped and an IABP was placed and a 5 french venous sheath placed into the left common femoral vein..  After stabilizing the patient, multiple attempts were made using a BMW wire, choice PT floppy tip wire and the pilot 50 wire to cross the proximal RCA were unsuccessful.  Patient was stable on IABP and emergently transferred to another institution for CABG.

The above are the highlights of the report.  

So far we have coded 93458-26, 33967,36556,92980 RC.

There is also always discussion about the IC nitro and the thrombolytics.  Could someone advise me to a reference or MC policy and both of those topics?

MJ


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## dpeoples (Mar 23, 2011)

10marty said:


> Danny, Theresa,
> 
> Thru the right radial artery he engaged the right coronary artery.  The catheterwas exchanged and multiple attempts were made to engage the left main, but proved to be unsuccessful thru the radial approach.  After 15-20 minutes I decided to to exchange to the right femoral artery and a #6 french sheath was introduced and secured in place.  The radial sheath was removed at that time and radial band placed with good hemostasis.  We started with a JL 3.5 diagnostic catheter, the left main inttubated and imaged..  We exchanged to pigtail in the LV gram was obtained.
> 
> ...



I would code:
92980 RC
93452-26 (LHC only, no interpretation of images/injections etc)
33967

I do not see enough documentation to support a non-tunnelled central line (36556) for the venous sheath in the left femoral vein. I would also be reluctant to code for thrombolytic to treat vasospams during an intervention such as this. I haven't time to search for a policy or specific reference but Zhealth has excellent publications.

HTH


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## 10marty (Mar 23, 2011)

Is there a code for insertion of a venous sheath for access in the femoral vein?


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## theresa.dix@tennova.com (Mar 24, 2011)

10marty said:


> Is there a code for insertion of a venous sheath for access in the femoral vein?



Marty,
I have a different answer then Danny in that I believe you should use the 93458-26 Let me tell you why. 93452 is a left heart cath that does not inlcude any evaluation of the coronary arteries. A cathether is inserted into the arterial system and into the Left Ventricle. It does not require a LV either it only requires crossing the aortic valve...This report states the cath was engaged into the Right Coronary thru the radial.( at first) and then into the left Main and images were taken (second).

So then you have your stent 92980-RC and IABP 33967-59( i believe) This is all you can code for this report. The antithrombolytic is not codeable or the nitro either. I dont have the guidelines right off hand but when I get more time I will try and find you something on that and post. 

I would not code the different entry sites for the vessels. They are included in the cath. 

Let me know your thoughts.!


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