# Appropriate to code attempted PTCA of Circumflex Artery?



## Chlrtrep (Apr 6, 2016)

Please review op note below. I would be interested in knowing if you feel it is appropriate for the facility to code attempted PTCA of Circumflex in this scenario.

Currently coded as:
C9600 LC
C9600 RC
92920-74

_My question is since the physician appears to electively stopped procedure and plans on bringing patient back when appropriate supplies are available should this not be coded.  Or is there any information to code 92920-74

PROCEDURE PERFORMED
1. Percutaneous coronary intervention of first obtuse marginal using 2.75 x
16 Promus stent.
2. Percutaneous coronary intervention of proximal right coronary artery
using 2.5 x 20 Promus stent.
3. Unsuccessful attempt to revascularize the distal circumflex due to
severe narrowing and inability to pass the smallest balloon across it.

INDICATIONS: The patient presented to the
emergency room with non-ST-elevation myocardial infarction. She had
coronary angiogram last week which showed multivessel disease with patent
LIMA to LAD graft. After discussion with the cardiac surgeons, decision was
to proceed with percutaneous coronary intervention, followed by
transcatheter aortic valve replacement. Benefits and risks of the procedure
were explained to the patient who agreed to proceed.

DESCRIPTION OF PROCEDURE: After informed consent was obtained, the
patient's right groin was prepped and draped in sterile fashion. Lidocaine
was used for local anesthesia. Access was obtained in the right common
femoral artery under fluoroscopic guidance with a 7-French sheath. We had
planned to proceed with revascularization of her circumflex and right
coronary arteries. CLS4 7-French guide was used to engage the left coronary
artery. Using BMW wire, we were able to pass with some difficulty all the
way into the distal circumflex artery. However, we were not able to pass
the balloon through the distal circumflex due to the severe narrowing at
the site. We used a 1.5 x 15 balloon with no success. This is the smallest
balloon that is available. We also tried using a GuideLiner to give more
support and pushability for the balloon to cross the blockage; however,
that failed. For that reason, I decided to abort further attempts at
revascularize that segment of the artery with the plan possibly to bring
her in the future once we have a smaller balloon and catheters available
for that kind of intervention. Following that, our attention was directed
towards the first obtuse marginal which had at least 90% narrowing
involving the ostial first obtuse marginal. Using BMW wire, we were able to
ascend all the way to the distal vessel. Predilatation was performed using
a 2.0 x 15 balloon followed by stenting using 2.75 x 16 stent. The proximal
part of the stent was then post-dilated using a 3 x 8 noncompliant balloon.
Final results with good angiographic results and no residual stenosis.
Following that, attention was directed towards the right coronary artery.
Using a 6-French JR4 guide catheter, we engaged the right coronary artery.
There was evidence of significant dampening of the ostium. Following that,
a BMW wire was passed all the way into the distal vessel. Balloon
predilatation was performed for the proximal right coronary artery which
had about 90% stenosis as well as balloon dilatation was performed for the
ostial right coronary artery. Following that, a 2.5 x 20 Promus stent was
advanced and deployed in the proximal right coronary artery with good
angiographic results. ***of the ostial right coronary artery showed no
significant disease and decision was to leave it alone without further
stenting. The patient tolerated the procedure well. At the end of the
procedure, hemostasis was obtained using Angio-Seal.

IMPRESSION
1. Successful revascularization of the first obtuse marginal and proximal
right coronary artery vessels.
2. Unsuccessful attempt to revascularize the distal circumflex artery due
to severe narrowing and inability to pass the smallest balloon across it.

RECOMMENDATIONS: Will optimize the patient's medical therapy for coronary
artery disease . Will consider in the near
future revascularizing the distal circumflex once we have the smallest
balloon size available for that procedure._


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## hofm04 (Apr 15, 2016)

Typically guidelines state to code the intended procedure.   If you only complete the balloon and don't even start the stent, you could go with balloon.


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