# stents



## nancy.anselmo@ccrheart.com (Jul 15, 2013)

INDICATIONS: Angina pectoris, coronary artery disease.

PROCEDURE: Left heart catheterization with selective coronary angiography, bypass graft angiography with complex bifurcation percutaneous intervention of the RPL and RPDA with placement of Resolute drug-eluting stents, complicated by no reflow.

HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old with history of hyperlipidemia, coronary artery disease, previous CABG x3 and subsequent PCI, presenting with progressive symptoms, fatigue, shortness of breath and angina. He had a poor 
performance on treadmill testing concerning for inferior ischemia despite maximal medical therapy and he is referred for diagnostic angiography.

PROCEDURE: Informed consent was obtained, the patient understood the risks, benefits and alternatives of the procedure and agreed to proceed with the procedure. 

PROCEDURE: Informed consent was obtained and the patient understood the risks, benefits and alternatives of the procedure and agreed to proceed with the procedure. The right groin was prepped in sterile fashion and 2% lidocaine infused subcutaneously 
until adequate anesthesia was obtained. Right common femoral artery accessed using modified Seldinger technique of which a 6 French 11 cm sheath was placed without complication. Diagnostic JL4 and JR4 and IMA catheters were used to perform selective 
coronary angiography, left ventriculography left heart catheterization and bypass graft angiography. At the conclusion of the procedure, an Angio-Seal device was deployed without complication.

HEMODYNAMICS: The left ventricular end-diastolic pressure measured 10 mmHg. There was no transaortic gradient on pullback. 

LEFT VENTRICULOGRAPHY: Deferred.

CORONARY ANGIOGRAPHY:
LEFT MAIN: Moderate disease leading into the LAD that was totally occluded proximally.

LAD: The midvessel segment LAD was seen filled in a retrograde fashion from patent IMA graft. The distant portion of the vessel had mild disease after the anastomosis. There were 2 diagonals that were visualized, both retrograde from a patent bypass 
graft. The first one was small and diffusely diseased. The second had mild disease.

CIRCUMFLEX: Small system in the AV groove with mild disease. The first marginal was totally occluded proximally but filled from a patent bypass graft. There was mild distal disease.

RCA: Totally occluded proximally. There was a patent graft leading into the distal vessel. At the bifurcation of the RPDA and RPL system, which was prominent and dominant, there were 2 tubular 90% type C stenoses. 

GRAFTS: The LIMA to LAD was patent. The vein graft to the marginal with mild disease and was patent. The saphenous vein graft to the right coronary artery was patent with mild disease.

SUMMARY: Severe multivessel coronary artery disease with high-grade disease after the anastomosis of the right coronary artery graft.

Based on the patient's clinical presentation and angiographic findings, it was decided to proceed with angioplasty.

INTERVENTION: Angiomax was used for effective anticoagulation and initially a JR4 guide catheter was used to intubate the right coronary artery. However, difficult catheter seating ensued and despite wiring of the vessel, inadequate guide seating was 
appreciated. The guide whipped out and was replaced with an MPA-1 guide. The lesions in the RPDA and RPL were navigated and Runthrough wires were placed in them respectively. A 2.5 balloon was used to predilate the lesion in the RPDA as well as in the
RPL. Next, a 2.5x18 Resolute drug-eluting stent was placed extending from the distal RCA into the RPDA. At this point in time, no refill was appreciated in the extensive RPL system. A subsequent PILOT wire was utilized to navigate with increased 
mental effort, and eventually was able to be placed within the distal RPL. However, upon attempting to retrieve the previously placed Runthrough wire, the wire appeared to snag and catch upon a lip of calcium and it was unable to be removed. A 2.0 
balloon was placed over the wire for further support and eventually the wire with dislodged and safely removed from the body. Next, a 2.0 balloon was able be placed across previous stented segment and dilated at the ostium, restoring blood flow to the 
RPL system. Next, a 2.25x18 Resolute was then placed into the RPL system and effectively deployed. Next, a 2.5 balloon was placed across within that same vessel and a 2.5 noncompliant balloon was placed in the previously stented RPDA. There were 
inflated in sequential kissing fashion for effective postdilation of the stented segments and the index lesions with an excellent angiographic result and TIMI-III flow.

SUMMARY: Successful complex percutaneous intervention of the RPDA and RPL, complicated by no flow in the RPL system.

I am not sure how to code this one 
I have
93459-26-59
92928-RC
92937? w/what Modifier Thanks Nancy


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## nancy.anselmo@ccrheart.com (Jul 16, 2013)

I really need some help here, when Dr said he went thru the bypass graft I got confused. Do I code a 92937 for that?


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## Jess1125 (Jul 16, 2013)

nancy.anselmo@ccrheart.com said:


> INDICATIONS: Angina pectoris, coronary artery disease.
> 
> PROCEDURE: Left heart catheterization with selective coronary angiography, bypass graft angiography with complex bifurcation percutaneous intervention of the RPL and RPDA with placement of Resolute drug-eluting stents, complicated by no reflow.
> 
> ...



Okay I see:
93459-26-59
92928-RC
92929-RC

I see stenting done in the RPDA and RPL. I don't see anywhere about these interventions being done through a vein graft at all. Anybody let me know if I'm missing something! 

Jessica CPC, CCC


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