# Medicare coding - I have one more case



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

I have one more case, I just want to be sure I am going in the right direction Thanks
INDICATIONS: Angina pectoris, coronary artery disease.

PROCEDURE: Left heart catheterization, selective coronary angiography, bypass graft angiography with percutaneous intervention to sequential lesions in the vein graft to the RCA with Resolute drug-eluting stents.

HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old with obesity, hypertension, diabetes, dyslipidemia and previous coronary disease with stenting to her vein grafts in 2007 and 2008 as she had previous bypass grafting in the late 1990s. She had a
vein graft to the LAD diagonal, vein graft to the OM1/OM2, and a vein graft to the RCA. She presented with progressive typical angina reaching level of class IV with minimal exertion at rest. She was maximized on medical therapy. She was initially 
referred for noninvasive stress testing. However, elected not to pursue and represents with progressive anginal symptoms and therefore it was decided to proceed with angiography.

PROCEDURE: Informed consent was obtained and the patient understood the risks, benefits and alternatives procedure and agreed to proceed with the procedure. The right groin was prepped in the usual 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 catheters were used to perform 
selective coronary angiography and left heart catheterization as well as bypass graft angiography. At the conclusion of the procedure, an Angio-Seal device was deployed without complication.

HEMODYNAMICS: Left ventricular end-diastolic pressure was elevated at 26 mmHg. There was no transaortic gradient on pullback.

LEFT VENTRICULOGRAPHY: Deferred due to the patient's elevated creatinine 

CORONARY ANGIOGRAPHY 
LEFT MAIN: Moderate disease.

LAD: Totally occluded proximally. It was seen filled in a retrograde fashion from patent bypass graft and in the distal vessel there was a 70% focal stenosis. There was a first diagonal that was diffusely diseased being seen filled from a patent 
bypass graft.

LEFT CIRCUMFLEX: Severely diseased. There was an 80% proximal lesion. The remaining aspect of the AV groove circumflex was subtotally occluded. The first two marginals were totally occluded; however, they were seen filled from a patent bypass graft 
and were moderately diffusely diseased.

RCA: Dominant. However, was totally occluded proximally. Distal vessel was seen filled from a diseased bypass graft. There was moderate disease distally with a prominent RPL and PL in RPDA systems. The vein graft to the LAD/diagonal was ectatic and 
large with moderate diffuse disease, however, no critical obstruction through the vessel or at the anastomosis. The vein graft to the marginal 1 and 2 was large and ectatic with moderate diffuse disease, however, no critical obstruction at the 
anastomosis or within the vessel. The vein graft to the RCA was patent; however, there was a 70% proximal stenosis as well as a 90% midvessel stenosis. In the distal vessel there was a previous stent with approximately 50% in-stent restenosis.

SUMMARY: Severe multivessel coronary artery disease with high-grade sequential vein graft lesions subtending a large RCA distribution. Bypass grafts were patent 5/5. However, there was severe disease in the RCA graft.

Based on the patient's clinical presentation with accelerating typical angina and class IV symptoms despite medical therapy, it was elected to proceed with angioplasty.

INTERVENTION: Angiomax was used for effective anticoagulation and eventually an MPA guide catheter was used to intubate the right coronary artery. A 2.225x3.5 FilterWire was then deployed distal to the sequential lesions both proximal and mid. Copious
amounts of intracoronary Nipride were used in order to maintain adequate flow and a 2.5 balloon was used to predilate the lesion. A 3.0x15 Resolute drug-eluting stent was then deployed to 16 atmospheres in the midvessel as well as another 3.0x15 
Resolute in the proximal to 16 atmospheres with an excellent angiographic result.

SUMMARY: Successful percutaneous intervention of the sequential lesions seen in the proximal and mid vein graft to the RCA with placement of Resolute drug-eluting stents. The filter was retrieved without issue. There were no complications or slow 
refill.

CLINICAL PATHWAY: The patient was loaded on Plavix and maintained on aspirin and Plavix as well as a secondary prevention regimen. We hope this will afford for symptomatic relief and will permit her to be more active and perhaps lose weight. We thank 
you for the opportunity to participate in the care of this lovely woman. 



   Procedure Codes:
  93459-26-59 

  92937-. I am not sure if I put modifier RC on this code or another modifier Thanks


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## Jess1125 (Jan 15, 2013)

nancy.anselmo@ccrheart.com said:


> I have one more case, I just want to be sure I am going in the right direction Thanks
> INDICATIONS: Angina pectoris, coronary artery disease.
> 
> PROCEDURE: Left heart catheterization, selective coronary angiography, bypass graft angiography with percutaneous intervention to sequential lesions in the vein graft to the RCA with Resolute drug-eluting stents.
> ...



I agree with your codes. I'd put the -RC on the 92937.
Jessica CPC, CCC


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

Thank you


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