# Second Visit After Surgery



## jtuominen (Dec 7, 2010)

Hi there--

Looking for opinions on how other coders might tackle this situation.

12/1: Patient presents with angina and abnormal stress test for coronary angiogram.
Coronary angiogram reveals stenosis of distal left main, extending into LAD, plus an additional LAD lesion. There is also a signifcant lesion in the RCA. MD decides to send patient to surgery for bypass.

12/2: Patient presents for bypass surgery. MD is able to place a RIMA and SVG graft to the right system. But when he tries to locate the LAD, it is buried too deep and the surgeon cannot locate the LAD. He sends the patient back to the cath lab for PCI to LMCA/LAD

12/3 - 12/5: Normal hospital course. No changes in patient's condition/symptoms.

12/6: Patient presents for pre-scheduled PCI to LMCA/LAD. MD does coronary angiogram along with RIMA and SVG gram prior to intervention, there are no new significant findings on angiogram. MD successfully performed PCI to LMCA and LAD.

Would you bill the patient for the second coronary angiogram on the 6th? Or for PCI only?


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## btadlock1 (Dec 7, 2010)

Seems like it was necessary to verify the patient's condition, so yeah, I probably would. Of course, if they don't have insurance, you may discuss it with the doctor to see if they just feel like being compassionate on the financial aspect. That can get pretty expensive, and piling on a huge medical bill might deter them from seeking treatment they could really need in the future. Just my opinion, though...


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## Jess1125 (Dec 7, 2010)

I would NOT bill for another coronary angio. 

#1) It is stated that the patient is coming in on 12/6 FOR an elective intervention. It was scheduled as an intervention.

#2) You also state that the patient's condition hasn't changed so the coronary angiogram wouldn't be a diagnostic study. Part of intervention.

Jessica CPC, CCC


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## btadlock1 (Dec 7, 2010)

jtuominen said:


> Hi there--
> 
> Looking for opinions on how other coders might tackle this situation.
> 
> ...





Jess1125 said:


> I would NOT bill for another coronary angio.
> 
> #1) It is stated that the patient is coming in on 12/6 FOR an elective intervention. It was scheduled as an intervention.
> 
> ...




I'm a little lost on this...I don't see how it was elective - it appears as though it was pre-scheduled on the 2nd after the surgeon encountered a complication trying to locate the LAD. The patient's condition may not have (apparently) changed between the 3rd and the 5th, but he DID have bypass surgery and an attempted PCI to LCMA/LAD on the 2nd, which was after the first angiogram. I can see how the second angio could be part of the intervention, but I can also see how it might be necessary to perform a second diagnostic study to confirm the need for additional intervention, and make sure that the patient's condition hasn't changed enough to affect the procedure. Would the original angiogram still be accurate after perfoming the initial bypass and attempted PCI? Is it possible that the surgery might have altered any aspect of the patient's condition (for better or worse), in a way that wouldn't be obvious without an angiogram, but might be significant enough to alter the plan of treatment?

(By the way - I'm not being argumentative, here - This is just how I learn. Cardiac codes are my weakness, so I just want to understand the logic used by someone who would actually know...)


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## jtuominen (Dec 7, 2010)

The patient was scheduled for diagnostic angiogram with possible PCI on 12/1. 

The op note from the cardiothoracic surgeon on 12/2 just states "I could not locate the LAD artery when attempted to place LIMA graft to LAD" with no real expansion as to why (I was really hoping to find some kind of disease process or congential anomaly for the reason why, but nothing other than he couldn't find it)

The 12/6 angiogram was prescheduled right away on 12/6 after the cardiothoracic surgeon spoke with the cardiology group after surgery on 12/2, when he reccommended the patient safest bet was PCI.

I feel like Ive got to have a new diagnosis or new symptom onset to bill the second angiogram, and I haven't got one.


But Im still waiting on a discharge summary. ick. 
More comments would be incredibly helpful!


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## btadlock1 (Dec 7, 2010)

Okay, so what prompted him to order the angiogram - was it something that the cardiothoracic surgeon said? Or does he just routinely order angio's for every PCI? You may have to just ask them if it's not clear in the documentation...If he doesn't always order those, then there had to have been some reason he thought he needed one this time. Does it happen to mention anything else about what the surgeon told him, or maybe an op report?

That's where your second diagnosis will be hiding...


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## jtuominen (Dec 8, 2010)

coronary angiograms on their own are performed for diagnositc purposes.
Routinely our physicians will schedule coronary angiograms with the possibility of PCI.
If this is the patient's first visit to the lab, we can charge the coronary angiogram along witht he PCI because the angiogram is diagnositc in nature, giving us the information we need to move on to intervention.

When our patient visited on 12/1, the procedure was scheduled as a coronary angiogram with possible PCI. When the interventionalist saw the extent of the disease, he determined the patient would be a better fit for bypass.

On 12/2, the bypass was partially completed, with grafts to the right system, but the surgeon said he couldn't locate the artery. Im still waiting to see if a diagnosis for this situation pops up, but so far all I've got is that he couldn't find it. Because of this the surgeon called the interventionalist, to let him know stents were going to be the only way to fix the patients left system.

I checked with scheduling and the patient was scheduled on 12/6 for PCI only.
The physician did a coronary angiogram prior to along with a selective shot of the new RIMA and SVG to the right. Angiogram prior to PCI is routine in most cases , so that you can get a good snapshot of the patient's extent and location of disease. Most docs won't do a straight stenting without at least taking a look prior to. It is pertinent to point out here that the physician doing this study was not the same as the first on 12/1, it was an associate of his that is in his practice.
From the information I have there was no signigicant change in the findings between the diagnositc angiogram on 12/1 and the one on 12/6. The patient had normal post-operative course over the weekend, with no real change in symtpoms that would warrant a charge for a second diagnostic study.


But of course, Im still waiting on a discharge summary, just to be sure.
ick!


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## btadlock1 (Dec 8, 2010)

So should the second physician have been comfortable relying on the original angio results, given that the first procedure didn't go as planned? If he had reason to think the first one was flawed, it would seem reasonable to order a second angio to confirm the diagnosis/problem area before operating to me. They may be in the same practice, but liability for the surgery would still fall on whomever is performing the operation...Is that not something that would make a second test medically necessary? 
(As I mentioned before, I honestly don't know - I'm trying to get a better understanding)


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## theresa.dix@tennova.com (Dec 10, 2010)

This is pretty simple actually. They already knew there was a lesion that needed attention in the LD. So no I would NOT charge another angiogram.This was not a diagnostic procedure since they already knew where the lesion was and what they had to do with it and nothing had changed.

Theresa Dix  CCS-P CCP CPMA CCC


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