# Cath, PCI Stent and Angioplasty



## amym (Jun 25, 2013)

Please help. I have not done any endovascular coding and a while and am not sure of the codes.  Can I bill for all of this? I have 93458-26, 92928-LC, 36215, 37205, 75960-26.

SUMMARY: 

-- CORONARY CIRCULATION: 
-- 2nd obtuse marginal: There was a 95 % stenosis. There was TIMI grade 2 
flow through the vessel (partial perfusion). This lesion is a likely 
culprit for the patient's anginal symptoms. 

-- CARDIAC STRUCTURES: 
-- Global left ventricular function was mildly depressed. EF calculated 
by contrast ventriculography was 45 %. 

-- HEMODYNAMICS: 
-- Hemodynamic assessment demonstrates normal hemodynamics and borderline 
systemic hypertension. 

-- DIAGNOSTIC PROCEDURES: 
-- Access obtained under ultrasound guidance 

-- 1ST LESION INTERVENTIONS: 
-- A successful balloon angioplasty with stent was performed on the 99 % 
lesion in the left subclavian artery. Following intervention there was an 
excellent angiographic appearance with a 0 % residual stenosis. 
-- A self-expanding EV3 stent was placed across the lesion and deployed. 

-- 2ND LESION INTERVENTIONS: 
-- A successful balloon angioplasty with stent was performed on the 95 % 
lesion in the 2nd obtuse marginal. Following intervention there was an 
excellent angiographic appearance with a 0 % residual stenosis. 

-- 3RD LESION INTERVENTIONS: 
-- A successful balloon angioplasty with stent was performed on the 95 % 
lesion in the mid circumflex. Following intervention there was an 
excellent angiographic appearance with a 0 % residual stenosis. 

PROCEDURES PERFORMED: 

-- Left heart catheterization with ventriculography. 
-- Right coronary angiography. 
-- Left coronary angiography. 
-- Right subclavian angiography. 
-- PTA. 
-- Coronary Bare Metal Stent Placement. 
-- Coronary Drug Eluding Stent Placement. 
-- Coronary Stent Placement. 
-- Intervention on left subclavian: balloon angioplasty, stent. 
-- Intervention on OM2: balloon angioplasty, stent. 
-- Intervention on mid circumflex: balloon angioplasty, stent. 

INDICATIONS: Angina/MI: unstable angina. 

HEMODYNAMICS: Hemodynamic assessment demonstrates normal hemodynamics and 
borderline systemic hypertension. 

VENTRICLES: Global left ventricular function was mildly depressed. EF 
calculated by contrast ventriculography was 45 %. 

CORONARY VESSELS: The coronary circulation is co-dominant. Ostial left 
main: Normal. Proximal left main: Normal. Mid left main: Normal. Distal 
left main: Normal. Proximal LAD: Normal. Mid LAD: Normal. Proximal 
circumflex: Normal. Mid circumflex: Normal. There was a 95 % stenosis. 
There was TIMI grade 2 flow through the vessel (partial perfusion). Distal 
circumflex: Normal. 1st obtuse marginal: Normal. 2nd obtuse marginal: 
There was a 95 % stenosis. There was TIMI grade 2 flow through the vessel 
(partial perfusion). This lesion is a likely culprit for the patient's 
anginal symptoms. Left AV groove artery: Normal. Proximal RCA: There was a 
100 % stenosis. 

ARCH VESSELS: Left subclavian: There was a 99 % stenosis. Right 
subclavian: The vessel was medium to large sized and mildly tortuous. 
Angiography showed multiple discrete lesions partial occlusion and 
aneurysmal dilatation. There was a discrete 99 % stenosis. The lesion was 
irregularly contoured and complex. An intervention was performed. Gradient 
evaluation: 70 mmHg (peak resting). Mid right subclavian: There was a 95 % 
stenosis at the site of a prior stent within the graft anastomosis. An 
intervention was performed. Gradient evaluation: 70 mmHg (peak resting). 
Distal right subclavian: There was a 80 % stenosis. 

PROCEDURE: The risks and alternatives of the procedures and conscious 
sedation were explained to the patient and informed consent was obtained. 
Access obtained under ultrasound guidance The patient was brought to the 
cath lab and placed on the table. The planned puncture sites were prepped 
and draped in the usual sterile fashion. 

-- Right brachial artery access. The puncture site was infiltrated with 
local anesthetic. The vessel was accessed using the modified Seldinger 
technique, a wire was threaded into the vessel, and a catheter was 
advanced over the wire into the vessel. 

-- Left heart catheterization. A catheter was advanced to the ascending 
aorta. After recording ascending aortic pressure, the catheter was 
advanced across the aortic valve and left ventricular pressure was 
recorded. Ventriculography was performed using power injection of contrast 
agent. Imaging was performed using an RAO projection. 

-- Right coronary artery angiography. A catheter was advanced to the 
aorta and positioned in the vessel ostium under fluoroscopic guidance. 
Angiography was performed in multiple projections using hand-injection of 
contrast. 

-- Left coronary artery angiography. A catheter was advanced to the aorta 
and positioned in the vessel ostium under fluoroscopic guidance. 
Angiography was performed in multiple projections using hand-injection of 
contrast. 

-- Right subclavian angiography. A catheter was positioned under 
fluoroscopic guidance. 

LESION #1 INTERVENTION: A successful balloon angioplasty with stent was 
performed on the 99 % lesion in the left subclavian artery. Following 
intervention there was an excellent angiographic appearance with a 0 % 
residual stenosis. This was an ACC/AHA "non-high risk" lesion for 
intervention. There was no acute vessel closure. There was no perforation. 
There was no dissection. 

-- Balloon angioplasty was performed, using a Rival 4 x 4 x 135 balloon, 
with 1 inflations and a maximum inflation pressure of 14 atm. During the 
procedure, a new BMW HT 300cm wire was advanced across the lesion. 

-- A self-expanding EV3 stent was placed across the lesion and deployed. 

-- Balloon angioplasty was performed, using a Rival 7 x 4 x 135 balloon, 
with 3 inflations and a maximum inflation pressure of 11 atm. 

LESION #2 INTERVENTION: A successful balloon angioplasty with stent was 
performed on the 95 % lesion in the 2nd obtuse marginal. Following 
intervention there was an excellent angiographic appearance with a 0 % 
residual stenosis. This was an ACC/AHA "non-high risk" lesion for 
intervention. There was TIMI 2 flow before the procedure and TIMI 3 flow 
after the procedure. There was no acute vessel closure. There was no 
perforation. There was no dissection. 

-- Balloon angioplasty was performed, using a Emerge Rx 2.0 x 12mm 
balloon, with 1 inflations and a maximum inflation pressure of 14 atm. 
During the procedure, the previous guider was changed for a Runway 6FR FL 
4 guider, and a new BMW HT 190cm wire was advanced across the lesion. 

-- A PE Plus MR 2.25 x 16 drug-eluting stent was placed across the lesion 
and deployed at a maximum inflation pressure of 18 atm. During the 
procedure, the previous guider was changed for a Runway 6FR FL 4 guider, 
and a new BMW HT 190cm wire was advanced across the lesion. 

-- Balloon angioplasty was performed, using a Emerge Rx 2.50 x 12mm 
balloon, with 1 inflations and a maximum inflation pressure of 7 atm. 
During the procedure, the previous guider was changed for a Runway 6FR FL 
4 guider, and a new BMW HT 190cm wire was advanced across the lesion. 

LESION #3 INTERVENTION: A successful balloon angioplasty with stent was 
performed on the 95 % lesion in the mid circumflex. Following intervention 
there was an excellent angiographic appearance with a 0 % residual 
stenosis. This was an ACC/AHA "non-high risk" lesion for intervention. 
There was TIMI 2 flow before the procedure and TIMI 3 flow after the 
procedure. There were no site complications. There was no acute vessel 
closure. There was no perforation. There was no dissection. 

-- Balloon angioplasty was performed, using a Emerge Rx 2.0 x 12mm 
balloon, with 1 inflations and a maximum inflation pressure of 14 atm. 
During the procedure, the previous guider was changed for a Runway 6FR FL 
4 guider, and a new BMW HT 190cm wire was advanced across the lesion. 

-- Balloon angioplasty was performed, using a Emerge Rx 2.50 x 12mm 
balloon, with 1 inflations and a maximum inflation pressure of 14 atm. 
During the procedure, the previous guider was changed for a Runway 6FR FL 
4 guider, and a new BMW HT 190cm wire was advanced across the lesion. 

-- A PE Plus MR 2.5 x 16 drug-eluting stent was placed across the lesion 
and deployed at a maximum inflation pressure of 16 atm. During the 
procedure, the previous guider was changed for a Runway 6FR FL 4 guider, 
and a new BMW HT 190cm wire was advanced across the lesion. 

CARDIAC INTERVENTIONS 
-- PTA. 

-- Coronary Bare Metal Stent Placement. 

-- Coronary Drug Eluding Stent Placement. 

-- Coronary Stent Placement. 

COMPLICATIONS: 
None occurred during the cath lab visit. 
PROCEDURE COMPLETION: The patient tolerated the procedure well. TIMING: 
Test started at 08:10. Test concluded at 11:03. RADIATION EXPOSURE: 

STUDY DIAGRAM 

Angiographic findings 
Native coronary lesions: 
7Mid circumflex: Lesion 1: 95 % stenosis. 
7OM2: Lesion 1: 95 % stenosis. 
7Proximal RCA: Lesion 1: 100 % stenosis. 
Intervention results 
Native coronary lesions: 
7Successful balloon angioplasty and stent of the 95 % stenosis in OM2. 
Appearance excellent with 0 % residual stenosis. Stent: PE Plus MR 2.25 x 
16 drug-eluting. 7Successful balloon angioplasty and stent of the 95 % 
stenosis in mid circumflex. Appearance excellent with 0 % residual 
stenosis. Stent: PE Plus MR 2.5 x 16 drug-eluting. 

HEMODYNAMIC TABLES 

Pressures: Baseline 
Pressures: - HR: 96 
Pressures: - Rhythm: 
Pressures: -- Aortic Pressure (S/D/M): 177/53/95 
Pressures: -- Left Ventricle (s/edp): 182/7/-- 

Outputs: Baseline 
Outputs: -- CALCULATIONS: Age in years: 81.34 
Outputs: -- CALCULATIONS: Body Surface Area: 1.46 
Outputs: -- CALCULATIONS: Height in cm: 152.00 
Outputs: -- CALCULATIONS: Sex: Female 
Outputs: -- CALCULATIONS: Weight in kg: 51.00


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## CPCCODERII (Jun 26, 2013)

I agree with your coding, however, I would also add 92929 for the stenting of OM2, and I would put a 59 on 93458-26 and also on 75960-26 as these show as bundled into the other procedures.  Kudos to your provider for such thorough documentation!


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