# Cardiology- AMI revascularization of Saphenous



## agiddens (Feb 5, 2013)

I have a question in regards to AMI revascularization of Saphenous vein graft, mid LAD, and distal LAD.

Graft to the mid LAD: The graft was a saphenous vein graft from the aorta with 100% stenosis/occlusion.

A successful stent with balloon angioplasty was performed on the 100% lesion in the distal anastomosis of the saphenous vein graft from the aorta to the mid LAD. Integrity bare metal stent was placed across the lesion and placed in the LAD. A balloon angioplasty was performed in the mid LAD. A balloon angioplasty was performed in the distal LAD.

What would the proper code selection be?


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## jewlz0879 (Feb 6, 2013)

I'm thinking 92941. I don't see that 'acute' or 'chronic' were indicated so I went with the fact that patient has AMI, which is acute MI. You may want to query the provider on this because the difference between 92941 and 92943 lies in the lay desciption: "ACUTE occlusion" or "CHRONIC occlusion." Without his solid documentation, it is somewhat a guess game IMO. 

HTH


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## agiddens (Feb 6, 2013)

jewlz0879 said:


> I'm thinking 92941. I don't see that 'acute' or 'chronic' were indicated so I went with the fact that patient has AMI, which is acute MI. You may want to query the provider on this because the difference between 92941 and 92943 lies in the lay desciption: "ACUTE occlusion" or "CHRONIC occlusion." Without his solid documentation, it is somewhat a guess game IMO.
> 
> HTH



The culprit lesion was identified in the mid LAD (92941-LD). 100% occlusion was also treated in the distal anastomosis of the SVG (not related to the MI). Is this bundled into the 92941 or is a seperate code added (i.e. 92941-59, 92937-59)? 

Thanks


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## jewlz0879 (Feb 6, 2013)

Ah, I read your question wrong, my apologies as I thought you were simply asking about 92941 v. 92943. Here is my thinking: we have the 92937 for the revascularization of SV graft; he also performs PTCA of LAD, and since we code by vessel and not lesions, I would go with: 92920. 

The reason I chose 92937 over 92941 is because this is a SV graft and not a CABG. Do you agree or disagree? Heck, I'm open! Maybe my train of thought is a hair off. 

Now, I do know that if a lesion extends from one artery to the other, then the direction is to bill one code. However, if we're talking about bifurcations, then we can bill for each. 

I may have to re-read this in the morning, LOL. 

Final answer for now, 92937 & 92920.  This is tough and making me think. 

Anyone else???? Please correct me if I am wrong....


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## jewlz0879 (Feb 7, 2013)

Man, I even went back over a couple webinars and no one seems to specifically talk about this or 92937 for that matter; it's like they just skip over it. I was hoping to see a couple examples so I would know if my thought process is correct. And I could be wrong but I'm going to try and find some more solid information on this.


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## agiddens (Feb 7, 2013)

*Cardiology 92941 vs. 92937*



jewlz0879 said:


> Man, I even went back over a couple webinars and no one seems to specifically talk about this or 92937 for that matter; it's like they just skip over it. I was hoping to see a couple examples so I would know if my thought process is correct. And I could be wrong but I'm going to try and find some more solid information on this.



Thank you so much Julie! I've researched 92937 and came up empty. I did find a PCI crosswalk on CardiologyCoder.com but still no explanation oh how to apply the code. Please keep me posted if you find any additional information.


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## jewlz0879 (Feb 7, 2013)

*PCI 92941 v 92937 and PTA*

I emailed Jim Pawloski (a regular on here and very good as what he does) here is his reponse: 

Hi Julie,
I am going to answer the report first. I agree with the 92937, but have questions about 92920, because the graft. Can we use the "graft" as the main coronary vessel, and the actual LAD as a branch, as in are they separate vessels? This is my question to the insurance carriers. I would consider it separate, and use the codes that you stated. As for 92937 and 92941, when I see a STEMI or a mention of chest pain, elevated tropenin (? lab value) or MI diagnosis, then I will bill for the diagnostic cath (Coronary or LHC) and 92941. I woud use 92937 when the cath is not emergent and the graft has been opened.
HTH,
Jim 


Also, I emailed Jim Collins. LOL We'll get an answer. I have to understand this.


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## agiddens (Feb 7, 2013)

*Cardiology 92941 vs. 92937*



jewlz0879 said:


> I emailed Jim Pawloski (a regular on here and very good as what he does) here is his reponse:
> 
> Hi Julie,
> I am going to answer the report first. I agree with the 92937, but have questions about 92920, because the graft. Can we use the "graft" as the main coronary vessel, and the actual LAD as a branch, as in are they separate vessels? This is my question to the insurance carriers. I would consider it separate, and use the codes that you stated. As for 92937 and 92941, when I see a STEMI or a mention of chest pain, elevated tropenin (? lab value) or MI diagnosis, then I will bill for the diagnostic cath (Coronary or LHC) and 92941. I woud use 92937 when the cath is not emergent and the graft has been opened.
> ...



Thank you for your assistance.  I will look forward to hearing Jim Collin's response.


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## dpeoples (Feb 7, 2013)

I hope you all don't mind me weighing in...

I don't see where the "culprit lesion" is clearly documented, did I miss that?

If the culprit is in the SV graft, I would code 92941, and 92920 both LD)

If the culprit is in the LD (not graft) I would code 92941 LD and no second code is warrented for the PTCA of the mid LD".

If the culprit lesion is bridging the SVG/LD anastomosis, and the stent placed there, then only one code is warranted. (92941-LD)

HTH


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## jewlz0879 (Feb 7, 2013)

That's why I'm confused. I see AMI and so I think 92941 but then I see PTA of a SV graft and think 92937.  

Can you help unconfuse me? LOL I can't wrap my head around this for some reason. Ugh.

Maybe this is an example of why we need solid documentation. 

Culptrit lesion: 100% lesion in the distal anastomosis of the saphenous vein graft. Or is this not good documentation?


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## agiddens (Feb 7, 2013)

*Cardiology 92941 vs. 92937*



dpeoples said:


> I hope you all don't mind me weighing in...
> 
> I don't see where the "culprit lesion" is clearly documented, did I miss that?
> 
> ...



The culprit lesion was identified in the mid LAD (92941-LD). 100% occlusion was also treated in the distal anastomosis of the SVG (not related to the MI).


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## agiddens (Feb 7, 2013)

jewlz0879 said:


> That's why I'm confused. I see AMI and so I think 92941 but then I see PTA of a SV graft and think 92937.
> 
> Can you help unconfuse me? LOL I can't wrap my head around this for some reason. Ugh.
> 
> ...



Julie can you email me at anitagiddens@yahoo.com?


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## dpeoples (Feb 7, 2013)

agiddens said:


> I have a question in regards to AMI revascularization of Saphenous vein graft, mid LAD, and distal LAD.
> 
> Graft to the mid LAD: The graft was a saphenous vein graft from the aorta with 100% stenosis/occlusion.
> 
> ...



I hope I don't sound nit-picky, I don't mean too. I do not see "culprit lesion" documented here, and the only blockage I do see documented, seems to be in the graft.

However, assuming the culprit is in the "mid LD" and that the SVG was also angioplastied, I would code: 92941-LD, and 92937 LD for the graft.

HTH


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## agiddens (Feb 7, 2013)

*Cardiology 92941 vs. 92937*



dpeoples said:


> I hope I don't sound nit-picky, I don't mean too. I do not see "culprit lesion" documented here, and the only blockage I do see documented, seems to be in the graft.
> 
> However, assuming the culprit is in the "mid LD" and that the SVG was also angioplastied, I would code: 92941-LD, and 92937 LD for the graft.
> 
> HTH




Thank you for your response. It was very helpful.


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## Jim Pawloski (Feb 7, 2013)

agiddens said:


> Thank you for your response. It was very helpful.



I just looked up this situation in Dr. Z's book, and he states (in my words, short version) that if the intervention is done in the graft, and the native artery intervention is done thru the native orifice, then you can bill for both.  But if the intervention is only through the graft, then you only code one intervention.  (Diagnostic & Interventional Cardiovascular Coding Reference, 2013 Seventh Edition), Pg. 98, #20)
HTH,
Jim Pawloski, CIRCC


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## dpeoples (Feb 8, 2013)

Jim Pawloski said:


> I just looked up this situation in Dr. Z's book, and he states (in my words, short version) that if the intervention is done in the graft, and the native artery intervention is done thru the native orifice, then you can bill for both.  But if the intervention is only through the graft, then you only code one intervention.  (Diagnostic & Interventional Cardiovascular Coding Reference, 2013 Seventh Edition), Pg. 98, #20)
> HTH,
> Jim Pawloski, CIRCC



Thanks Jim, that makes sense.


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