# How to code and what modifiers to use - Coronary angiography with complex



## nancy.anselmo@ccrheart.com (Aug 20, 2013)

INDICATIONS: Angina pectoris.

PROCEDURE: Coronary angiography with complex percutaneous intervention of the RCA after a significant fractional flow reserve with placement of Resolute drug-eluting stent, complicated by aorto-ostial dissection, covered with Resolute drug-eluting stent

HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old with history of coronary artery disease, previous stents in the past to her left circumflex and RCA who presents with escalating symptoms of typical angina despite maximal medical therapy. She 
declined noninvasive risk stratification due to foot a injury that preclude treadmill exercise and adverse reactions previously to a pharmacologic stress test. She presents for coronary angiography.

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 wrist was prepped in the usual sterile fashion and 2% lidocaine infused 
subcutaneously until adequate anesthesia was obtained. Right radial artery accessed using modified Seldinger technique of which a 6 French 250 mm sheath was placed without complication. Diagnostic 6 French Jacky catheter was used to perform selective 
coronary angiography. At the conclusion of the procedure, a compression band was used for hemostasis.

CORONARY ANGIOGRAPHY:
LEFT MAIN: Mild disease.

LAD: Moderate disease. It was tortuous in its course. There were two 70% sequential stenoses seen in the distal vessel. There were eccentric and tubular in nature. There was a small tortuous diagonal that had mild disease.

CIRCUMFLEX: Gave off a prominent first marginal. There was a patent proximal stent in the left circumflex with mild diffuse disease.

RCA: Large, dominant system with prominent PL and PDA branches. It was extremely tortuous. There were patent stents seen in the proximal midvessel portion. Due to the patient's dilated aorta, the takeoff of the ostium of the RCA was inferior and 
posterior. Deep seated catheter placement was utilized for coronary injection. There appeared to be a 70% focal stenosis seen in the midvessel within stent.

INTERVENTION: Due to the intermediate nature of this disease and no previous noninvasive testing, a fractional flow reserve was used. An MPA guide was used to intubate the right coronary artery. A RADI wire was placed to the distal vessel and maximal 
hyperemia was achieved with 182 mcg of adenosine with maximal hyperemia achieved. There was a peak gradient of 0.79 was with achieved, determined to be significant. There was evidence of wire bias and artifact in the proximal portion upon engagement. 
A 2.5 balloon was used to predilate the lesion and a 3.0 Resolute was deployed within the segment of stenosis with 0% residual stenosis. Attention was drawn to the ostium where there appeared to be some ostial staining as well as the superior roof 
dissection. A 3.5 Resolute was then deployed and the ostium was flared. There appeared to be tacking up the dissection within the coronary vessels; however, there appeared to be residual aorto-ostial staining. The patient was hemodynamically stable 
without complaints of chest pain. The patient's anticoagulants were discontinued. 

The patient will be watched judiciously for potential development of complication. A stat echo will also be achieved. She will be maintained on medical therapy and we will initiate a CT consult to get them on board should her situation decline. We 
thank you for the opportunity to participate in the care of this lovely woman.

I have 92928-RC
93454-26-59
93571-RC-26
93312-26
93325-26
93320-26
Dr did a TEE following the Cath and Stent so would I put modifier 58 on the TEE codes or what? Thank you Nancy


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## Jess1125 (Aug 20, 2013)

nancy.anselmo@ccrheart.com said:


> INDICATIONS: Angina pectoris.
> 
> PROCEDURE: Coronary angiography with complex percutaneous intervention of the RCA after a significant fractional flow reserve with placement of Resolute drug-eluting stent, complicated by aorto-ostial dissection, covered with Resolute drug-eluting stent
> 
> ...



I agree with your codes for the coronary angio/intervention/FFR. 

Your codes for the TEE would be correct as well. You shouldn't need any other modifiers on the TEE other than the -26 modifiers. 

Jessica CPC, CCC


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## TWinsor (Aug 21, 2013)

I agree also but have found with several of our payers even though there is no CCI edits for the TEE on the same day as the cath procedure we still have to add a -59 to the 93312 for payment.

HTH!


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