Hi list,
Everything is running together in my brain thismorning and needed a second set of eyes.
I am not worried about the other CPT codes that accompany in this report, I have those, but would you code 92920 or 92943? Any advice is greatly appreciated!!
PROBLEM LIST:
1. Recent episode of flash pulmonary edema.
2. Coronary artery disease, status post stenting of the right coronary
artery in 2005 with the use of a Taxus stent.
3. Mild systolic dysfunction with an LVEF of 49% with inferior
hypokinesis.
4. Acute on chronic renal failure.
5. Uncontrolled hypertension, suspicious for renal artery stenosis.
6. Hyperlipidemia.
7. History of lymphoma, status post chemotherapy.
PROCEDURES PERFORMED:
1. Coronary angiogram.
2. Abdominal aortogram.
3. Selective left renal angiogram.
4. PTCA of the distal circumflex in the AV groove with the use of a 2.5 x
15 Trek balloon.
5. Right femoroiliac angiogram.
6. Arteriotomy closure.
PROCEDURE IN DETAIL:
After the recently performed H P was reviewed, the patient was interviewed
and examined. Risks and benefits of the procedure were explained to the
patient, who agreed to proceed. The informed consent was obtained. The
patient was brought to the catheterization laboratory where a time-out
procedure confirmed her name, date of birth and procedures to be performed.
Both groins were prepped in the usual sterile condition and marked for
possible access. A total of 15 mL of lidocaine were injected in the right
groin area. Access was obtained in the right common femoral artery using
the micropuncture system and the modified Seldinger technique. The
micropuncture sheath was upsized over an 0.035 wire to a 6-French 11 cm
long Terumo sheath. Over another 0.035 wire to the ascending aorta, a JL5
catheter was advanced to the ascending aorta. The wire was then removed.
Selective cannulation of the left main coronary artery was then performed.
Left coronary angiography was performed by hand injection of contrast in
multiple projections and revealed patent left main with less than 10%
stenosis. The proximal LAD, mid LAD and distal LAD had only mild plaquing.
There is a large diagonal vessel with only mild plaquing. The left main
gives origin to a circumflex coronary artery with only mild plaquing
proximally in the mid segment. It gives origin to a small OM1 and a large
OM2. The circumflex travels through the AV groove to give origin to a
third OM, has 90% ostial stenosis, followed by a small segment of a CTO in
the third OM vessel, which is a rather small vessel. The catheter was
de-engaged from the ostium of the left main coronary artery, was exchanged
over an 0.035 wire to a JR4 catheter. The wire was then removed.
Selective cannulation of the right coronary artery was then performed.
Right coronary angiography was performed by hand injection of contrast in
multiple projections and revealed a large dominant RCA that gives origin to
the PDA and a PLV. There is a patent stent in the proximal RCA. There is
only mild plaquing in the proximal portion of the PDA. The PLV has only
mild plaquing. The catheter was de-engaged from the ostium of the right
coronary artery and was exchanged over an 0.035 wire to an Omni select 1
catheter that was selectively engaged on the left renal artery. Left renal
angiogram revealed patent renal artery with no significant stenosis. We
were unable to cannulate the ostium of the right renal artery. Therefore,
an Omniflush catheter was advanced to the abdominal aorta and abdominal
aortogram was performed by power injection of contrast in the LAO
projection and revealed the presence of 2 accessory renal arteries to the
right kidney with no evidence of stenosis. The catheter was then removed
out of the body over an 0.035 wire. Decision was made to proceed to an
intervention in the OM3 vessel. Bolus of Angiomax was given. ACT was
documented to be 290 seconds. Abbott 3.5 catheter was advanced over
another 0.035 wire to the ascending aorta. We were able to cross the
proximal stenosis in the OM with the use of Prowater wire; however, using a
Whisper Prowater supporting different balloons, we were unable to cross the
short CTO in the middle of the OM2. Decision was made to proceed to an
angioplasty only of the ostium of the third OM. Angioplasty was performed
with the use of a 2.5 x 15 Trek balloon up to 6 atmospheres x20 seconds.
Followup angiogram revealed significant improvement in the stenosis in the
ostium of the OM1 from 90% to less than 20%. There was no evidence of
dissection or distal vessel embolization. It was considered to be a good
angiographic result, so the procedure was concluded. The catheter was
retrieved from the ostium of the left main coronary artery. The other
0.035 wire was advanced over the catheter. The catheter was removed out of
the body. Right femoroiliac angiogram was performed by hand injection of
contrast in the RAO projection and revealed a patent right external iliac,
common femoral artery and proximal superficial and profunda femoral artery
with an entry site in the midportion of the right common femoral artery.
Decision was made to close the right common femoral artery arteriotomy site
with the use of a StarClose device. The device was deployed. Immediate
hemostasis was accomplished. The patient tolerated the procedure well and
is being transferred to the recovery area in stable conditions.
FINDING DETAILS:
1. Coronary angiogram:
Left main, less than 10% plaquing.
Mild plaquing in the proximal, mid and distal LAD. There is a large
diagonal vessel with only mild plaquing.
Circumflex gives origin to a small OM1 and a large branching OM2 with only
mild plaquing. There is 90% ostial stenosis in the circumflex going to the
third OM. The third OM itself is a small vessel with 100% occlusion.
RCA is large dominant with a patent stent proximally. 40% stenosis in the
proximal PDA.
2. Abdominal aortogram.
Patent bilateral renal arteries.
There are 2 accessory renal arteries on the right and diffuse
atherosclerosis in the abdominal aorta.
3. Selective left renal angiogram:
The left renal artery is widely patent.
4. PTCA of the distal circumflex/ostial third OM:
Preprocedure stenosis 90%,
Postprocedure stenosis less than 20%.
It was PTCA'd with the use of a 2.5 x 15 Trek balloon at 6 atmospheres x20
seconds.
The final angiographic result was excellent with less than 20% residual
stenosis. No evidence of vessel dissection or distal vessel embolization.
5. Right femoroiliac angiogram:
Patent right external iliac, common femoral artery and proximal superficial
and profunda femoral artery.
6. Closure. Successful closure of the right common femoral artery
arteriotomy site with the use of a StarClose device.
RECOMMENDATIONS:
The patient is to continue dual antiplatelet therapy at least for 6 weeks
after this procedure. I have decided to stop her lisinopril given her
kidney dysfunction. We will initiate therapy with amlodipine. We will
continue fluid hydration with the use of bicarbonate.
150 /
512-352-5251
dd: 03/20/2013 05:11 P dt: 03/20/2013 09:51 P
Job #: 579622 / 19083337
Doc ID#: 824621
Everything is running together in my brain thismorning and needed a second set of eyes.
I am not worried about the other CPT codes that accompany in this report, I have those, but would you code 92920 or 92943? Any advice is greatly appreciated!!
PROBLEM LIST:
1. Recent episode of flash pulmonary edema.
2. Coronary artery disease, status post stenting of the right coronary
artery in 2005 with the use of a Taxus stent.
3. Mild systolic dysfunction with an LVEF of 49% with inferior
hypokinesis.
4. Acute on chronic renal failure.
5. Uncontrolled hypertension, suspicious for renal artery stenosis.
6. Hyperlipidemia.
7. History of lymphoma, status post chemotherapy.
PROCEDURES PERFORMED:
1. Coronary angiogram.
2. Abdominal aortogram.
3. Selective left renal angiogram.
4. PTCA of the distal circumflex in the AV groove with the use of a 2.5 x
15 Trek balloon.
5. Right femoroiliac angiogram.
6. Arteriotomy closure.
PROCEDURE IN DETAIL:
After the recently performed H P was reviewed, the patient was interviewed
and examined. Risks and benefits of the procedure were explained to the
patient, who agreed to proceed. The informed consent was obtained. The
patient was brought to the catheterization laboratory where a time-out
procedure confirmed her name, date of birth and procedures to be performed.
Both groins were prepped in the usual sterile condition and marked for
possible access. A total of 15 mL of lidocaine were injected in the right
groin area. Access was obtained in the right common femoral artery using
the micropuncture system and the modified Seldinger technique. The
micropuncture sheath was upsized over an 0.035 wire to a 6-French 11 cm
long Terumo sheath. Over another 0.035 wire to the ascending aorta, a JL5
catheter was advanced to the ascending aorta. The wire was then removed.
Selective cannulation of the left main coronary artery was then performed.
Left coronary angiography was performed by hand injection of contrast in
multiple projections and revealed patent left main with less than 10%
stenosis. The proximal LAD, mid LAD and distal LAD had only mild plaquing.
There is a large diagonal vessel with only mild plaquing. The left main
gives origin to a circumflex coronary artery with only mild plaquing
proximally in the mid segment. It gives origin to a small OM1 and a large
OM2. The circumflex travels through the AV groove to give origin to a
third OM, has 90% ostial stenosis, followed by a small segment of a CTO in
the third OM vessel, which is a rather small vessel. The catheter was
de-engaged from the ostium of the left main coronary artery, was exchanged
over an 0.035 wire to a JR4 catheter. The wire was then removed.
Selective cannulation of the right coronary artery was then performed.
Right coronary angiography was performed by hand injection of contrast in
multiple projections and revealed a large dominant RCA that gives origin to
the PDA and a PLV. There is a patent stent in the proximal RCA. There is
only mild plaquing in the proximal portion of the PDA. The PLV has only
mild plaquing. The catheter was de-engaged from the ostium of the right
coronary artery and was exchanged over an 0.035 wire to an Omni select 1
catheter that was selectively engaged on the left renal artery. Left renal
angiogram revealed patent renal artery with no significant stenosis. We
were unable to cannulate the ostium of the right renal artery. Therefore,
an Omniflush catheter was advanced to the abdominal aorta and abdominal
aortogram was performed by power injection of contrast in the LAO
projection and revealed the presence of 2 accessory renal arteries to the
right kidney with no evidence of stenosis. The catheter was then removed
out of the body over an 0.035 wire. Decision was made to proceed to an
intervention in the OM3 vessel. Bolus of Angiomax was given. ACT was
documented to be 290 seconds. Abbott 3.5 catheter was advanced over
another 0.035 wire to the ascending aorta. We were able to cross the
proximal stenosis in the OM with the use of Prowater wire; however, using a
Whisper Prowater supporting different balloons, we were unable to cross the
short CTO in the middle of the OM2. Decision was made to proceed to an
angioplasty only of the ostium of the third OM. Angioplasty was performed
with the use of a 2.5 x 15 Trek balloon up to 6 atmospheres x20 seconds.
Followup angiogram revealed significant improvement in the stenosis in the
ostium of the OM1 from 90% to less than 20%. There was no evidence of
dissection or distal vessel embolization. It was considered to be a good
angiographic result, so the procedure was concluded. The catheter was
retrieved from the ostium of the left main coronary artery. The other
0.035 wire was advanced over the catheter. The catheter was removed out of
the body. Right femoroiliac angiogram was performed by hand injection of
contrast in the RAO projection and revealed a patent right external iliac,
common femoral artery and proximal superficial and profunda femoral artery
with an entry site in the midportion of the right common femoral artery.
Decision was made to close the right common femoral artery arteriotomy site
with the use of a StarClose device. The device was deployed. Immediate
hemostasis was accomplished. The patient tolerated the procedure well and
is being transferred to the recovery area in stable conditions.
FINDING DETAILS:
1. Coronary angiogram:
Left main, less than 10% plaquing.
Mild plaquing in the proximal, mid and distal LAD. There is a large
diagonal vessel with only mild plaquing.
Circumflex gives origin to a small OM1 and a large branching OM2 with only
mild plaquing. There is 90% ostial stenosis in the circumflex going to the
third OM. The third OM itself is a small vessel with 100% occlusion.
RCA is large dominant with a patent stent proximally. 40% stenosis in the
proximal PDA.
2. Abdominal aortogram.
Patent bilateral renal arteries.
There are 2 accessory renal arteries on the right and diffuse
atherosclerosis in the abdominal aorta.
3. Selective left renal angiogram:
The left renal artery is widely patent.
4. PTCA of the distal circumflex/ostial third OM:
Preprocedure stenosis 90%,
Postprocedure stenosis less than 20%.
It was PTCA'd with the use of a 2.5 x 15 Trek balloon at 6 atmospheres x20
seconds.
The final angiographic result was excellent with less than 20% residual
stenosis. No evidence of vessel dissection or distal vessel embolization.
5. Right femoroiliac angiogram:
Patent right external iliac, common femoral artery and proximal superficial
and profunda femoral artery.
6. Closure. Successful closure of the right common femoral artery
arteriotomy site with the use of a StarClose device.
RECOMMENDATIONS:
The patient is to continue dual antiplatelet therapy at least for 6 weeks
after this procedure. I have decided to stop her lisinopril given her
kidney dysfunction. We will initiate therapy with amlodipine. We will
continue fluid hydration with the use of bicarbonate.
150 /
512-352-5251
dd: 03/20/2013 05:11 P dt: 03/20/2013 09:51 P
Job #: 579622 / 19083337
Doc ID#: 824621