# Coding help Please - INDICATIONS: Angina pectoris.



## nancy.anselmo@ccrheart.com (Aug 2, 2013)

INDICATIONS: Angina pectoris.

Left heart catheterization, selective coronary angiography with fractional flow reserve assessment of left circumflex, with intravascular ultrasound assessment of the left circumflex, bilateral renal angiography.

HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old with history of coronary artery disease, resistant hypertension, renovascular hypertension, multiple stents who presented with atypical symptoms of weakness, fatigue. He has been treated for 
hypothyroidism. He has a low resting heart rate. However, his symptoms were similar to symptoms prior to his previous interventions. He had a stress test 3 months ago that was low risk. However, with ongoing symptoms, the patient requests 
angiography.

PROCEDURE: Informed consent was obtained, the patient understood the risks, benefits and alternatives of the procedure and agreed to proceed with the procedure. The right groin was prepped in the usual sterile fashion. The right groin was prepped in 
the usual sterile fashion and 2% lidocaine infused subcutaneously until adequate anesthesia was obtained. Right common femoral artery was 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. At the conclusion of the procedure, an Angio-Seal device was deployed without complication.

HEMODYNAMICS: Left ventricular end-diastolic pressure measured 12 mmHg. There was no transaortic gradient on pullback. 

Bilateral selective renal angiography was performed with a JR4 catheter. It appeared that there was an accessory renal artery on the left of which both were selectively injected, without evidence of ostial stenosis and excellent reflux, full engorgement
of the renal arcades. The renal size is normal. Selective renal angiography was performed of the right renal artery which was selectively engaged. There was no evidence of ostial proximal stenosis, no catheter dampening, with good reflux and 
excellent engorgement the arcades with normal renal size.

CORONARY ANGIOGRAPHY:
LEFT MAIN: Mild disease.

LAD: Had patent stents seen in its proximal portion. There was moderate disease after the stents and 2 small diagonals. In the second diagonal, there was a questionable intermediate ostial stenosis. There was a ramus intermedius that had stent in its
proximal portion that had moderate disease. There was about 30% proximal instent restenosis. 

CIRCUMFLEX: The left circumflex gave off a prominent marginal branch. This too had stents at its ostium. There appeared to be an intermediate critical ostial stenosis; however, this could also be mach effect at the bifurcation with the stents in the 
ramus overlapping.

RCA: Dominant vessel with prominent PL and PDA branch with mild-moderate diffuse disease, but no significant obstruction.

SUMMARY: Mild nonobstructive coronary artery with patent stent seen in the LAD and circumflex; however intermediate stenosis at the ostium of the left circumflex consistent with either critical stenosis versus mach effect.

Based on these intermediate findings, fractional flow reserve was employed.

INTERVENTION: Angiomax was used for effective anticoagulation. An EBU 3.75 guide catheter was used to intubate the left main coronary artery. A flow wire was placed to the distal circumflex and maximal hyperemia with 182 mcg of adenosine were injected
with a peak gradient of 0.97, determined not to be significant. Multiple views suggested, however, this would be significant and concern that it was missing an ostial lesion. Intravascular ultrasound was then employed. A Runthrough wire was placed to
the distal vessel and a Volcano Eagle Eye intravascular ultrasound was then delivered across the lesion. Multiple passes and runs were done in both 2D and ChromaFlo. Multiple measurements were done, the index lesion of which there was a minimal 
diameter of 1.8 mm, maximum diameter 2.1 mm, with an area of 2.9 m2. The reference portion of the vessel was also measured with a minimum diameter 2.8 mm, maximum diameter of 2.9 mm and an area of 6.1 m2, translating to a 53% area stenosis. This is 
determined not to be significant.

SUMMARY: Nonsignificant lesion in the proximal circumflex.

I have not coded this before. I have 
93458-26-59
36252
93571-26-LC
92978-LC  Is this correct? Thank you Nancy


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## Misty Dawn (Aug 2, 2013)

I agree with your codes  Just to check I ran it CCI and none of the codes bundle so I don't think you need the 59 modifier on the HTC and not sure if you need the vessel modifer either. I know for Noridian we don't use them on the FFR(93571) and IVUS (92978) codes. Might check your payer guidelines for that.


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## nancy.anselmo@ccrheart.com (Aug 5, 2013)

Thank you for your help


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## nancy.anselmo@ccrheart.com (Aug 5, 2013)

I just have one more question, is the 36252 a code for the physican to bill? Not billing facility


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