# How to code and what modifiers to use - Left heart catheterization, selective



## nancy.anselmo@ccrheart.com (Sep 24, 2013)

PROCEDURE: Left heart catheterization, selective coronary angiography, left ventriculography with complex percutaneous intervention of the proximal left circumflex and obtuse marginal with placement of Resolute drug-eluting stents

HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old with hypertension, dyslipidemia and significant peripheral artery disease who presents with escalating symptoms of shortness of breath and dyspnea on exertion. He had a limited performance on the
treadmill with a significant drop in exercise time with concerning features for underlying ischemia. He is referred for diagnostic angiography despite maximizing medical therapy.

DESCRIPTION OF PROCEDURE: Informed consent was obtained, the patient understood the risks, benefits and alternatives of the procedure and agreed to proceed with the procedure. Whisper both groins were prepped in the usual sterile fashion. Access was 
attempted at the left common femoral artery, however, due to extensive peripheral artery disease the wire would not pass. The right radial approach was then elected. A 6 French 250 mm Glidesheath was placed without complication. Diagnostic 6 French 
Jacky catheter as well as a JL4 diagnostic catheter was used to perform selective coronary angiography, left heart catheterization and ventriculography. At the conclusion of the procedure, a vascular compression device was used for hemostasis.

FINDINGS: 
HEMODYNAMICS: Left ventricular end-diastolic pressure measured 11 mmHg. There was no significant transaortic gradient upon pullback.

VENTRICULOGRAPHY: Demonstrated preserved left ventricular function, ejection fraction 60%.

CORONARY ANGIOGRAPHY:
LEFT MAIN: Mild disease.

LAD: Extensive adventitial calcium with mild to moderate diffuse disease, but no significant obstruction. There was a small diagonal that had mild disease without significant obstruction.

LEFT CIRCUMFLEX: System was a large system with a prominent trifurcating first marginal. It had an extremely tortuous proximal segment. There was eccentric 70% stenosis. Within the first marginal, there was a 70% tubular stenosis prior to the 
trifurcation. The lower lying second marginal had mild disease.

RCA: Diffusely diseased vessel. There was a 40% proximal stenosis. There was a prominent RV marginal branch that had a 70% long tubular stenosis. This would be prominent enough that would accept angioplasty if deemed indicated.

Significant 2-vessel coronary artery disease with significant disease in the proximal left circumflex first marginal as well as in an RV marginal off the right coronary artery.

Based on the angiographic findings, the patient's clinical presentation despite medical therapy, it was elected to proceed with angioplasty of the left circumflex system.

INTERVENTION: Angiomax was used for effective anticoagulation. An EBU 3.75 guide catheter was used to intubate the left main coronary artery. Then a 2.5 balloon 2.5 x 12 apex was used to predilate the marginal lesions as well as at the proximal left 
circumflex. Next, a stent was attempted to be delivered. However, due to extreme tortuosity seen in the proximal segment and residual stenosis it was unable to pass. Multiple attempts were utilized as well as multiple wires. A second Runthrough was 
placed and this was ineffective.

Next, a third long Runthrough was placed and over which a Transit catheter was administered to exchange out for a Wiggle wire. Now with the support of 2 wires as well as a Wiggle wire a stent was attempted to be placed. A 2.5 x 26 Resolute was able to
cover the proximal segment after sequential predilatation was achieved. This would not pass into the marginal system. It was therefore deployed to high pressure. Next, the short Runthrough wires were removed and attempt to be redirected; however, 
this was not accomplished due to residual extreme tortuosity. A 2.5 noncompliant balloon was then dilated on multiple passes. Next, a 2.5 x 14 Resolute was placed in an overlapping fashion proximal to the diseased segment in the marginal. This covered
a distal edge dissection. However, it would not pass more distally to just prior to the bifurcation due to residual stenosis. Multiple balloons were applied; however the lesion would not yield . A 2.5 noncompliant balloon to high pressure was 
deployed. This did not allow for passage of the stent and therefore there was an acceptable result with TIMI-III flow and the procedure was concluded, after sequential high pressure post-dilatations with a 2.5 noncompliant balloon in the recently 
stented segments.

SUMMARY: Complex percutaneous intervention of the proximal circumflex and first obtuse marginal with balloon angioplasty of the distal marginal.

I have
93458-26-59
92928-LC-22 nothing else right? Thanks


----------



## nancy.anselmo@ccrheart.com (Sep 25, 2013)

We really need help w/this Thanks


----------



## theresa.dix@tennova.com (Oct 4, 2013)

Nancy,
 Yes I would code it with the codes you have there except I would not add the 22 modifier. For me to add the 22 I would have to see documentation from the physician that it took more time and effort then the usually lhc/stenting procedure. Even tho we see that it did take more time then the usually the physician didnt mention that it did.


----------



## csdarrow@hotmail.com (Oct 4, 2013)

Nancy,
I would code it like this:
92928.LC, 93458.26.59
Your highest dollar code goes first, this is a medicare pt and they are only going to pay a portion of the cath code, so list it second. Also, they are never going to pay extra for a modifier 22, so you only slow down your payment process by adding that in this case. the claim will come flying back as a denial and you would have to resubmit (wasted time). Hope this helps!
Chris CPC


----------



## dpeoples (Oct 7, 2013)

csdarrow@hotmail.com said:


> Nancy,
> I would code it like this:
> 92928.LC, 93458.26.59
> Your highest dollar code goes first, this is a medicare pt and they are only going to pay a portion of the cath code, so list it second. Also, they are never going to pay extra for a modifier 22, so you only slow down your payment process by adding that in this case. the claim will come flying back as a denial and you would have to resubmit (wasted time). Hope this helps!
> Chris CPC



I agree with Chris.


----------

