Cardiology Coding Alert

Case Description

Pulmonary embolism (PE) is the third most common cause of death in the United States, with at least 650,000 cases occurring annually. The highest incidence of recognized PE occurs in hospitalized patients.

For example, an 83-year-old woman with Parkinsons disease, who had been admitted nine days earlier for a fever and elevated creatine kinase (CK), suddenly stated that she could not breathe and collapsed from cardiopulmonary arrest. The successful cardioversion included prolonged closed chest massage, after which she was mechanically ventilated. Her blood pressure was being supported on dopamine.

Pulmonary angiography remains the gold standard for the diagnosis of PE. A positive one provides virtually 100 percent certainty that an obstruction to pulmonary arterial blood flow does exist and a negative one provides greater than 90 percent certainty in the exclusion of pulmonary embolism.

Procedure

In the cardiac cath laboratory, after the patients groin was prepped, draped and infiltrated in the usual manner, a
7-French sheath was placed into the right femoral vein. A pigtail catheter was advanced to the right main pulmonary artery and a pulmonary angiogram was done using 40cc of contrast. Next, a similar angiogram was done in the left artery. After the angiogram showed extensive pulmonary emboli, the cardiologist consulted with one of the practices partners.

I expressed to him my great concern about using even regional thrombolytic therapy with urokinase in a setting of a flail chest and protracted closed chest massage, especially in an 83-year-old lady. He concurred. We agreed that it would be best to try to mechanically agitate these larger pulmonary arteries in an attempt to open up a good canal so that the spontaneous lysis of thrombus could occur with restoration of some blood flow. Then we would placed a Greenfield filter and heparinize, watching carefully.

The cardiologist used a wire to carefully agitate the left lower lobe and right lower lobe pulmonary artery, hoping to disburse the clot burden and to expose greater surface area to clot erosion with blood flow.

Then he performed a vena cavagram and a Braun filter was deployed below the renal vein entry to prevent further embolization. The findings from the operative report were as follows:

1. Fluoroscopy: The pulmonary markings are
enhanced.

2. Hemodynamics: The pulmonary pressure is 50/30.

3. Pulmonary angiography: The main pulmonary artery appears not to be obstructed and not to possess significant amounts of thrombus. However, there is a thrombus in the right upper lobe artery and one to the right middle lobe artery. The right lower lobe artery is almost totally thrombus filled with very little contrast getting past. There is amputation of some of the vessels to the right upper lobe. The pulmonary arteriogram in the left main pulmonary artery shows extensive pulmonary emboli, [...]