Wiki Am I on the right path?

[calorom2]

Would this be a 93454 and a 92928 or just 92928? The patient was scheduled for a left heart cath but I don't see that (or a right) here. Any assistance as I am learning would be appreciated.

Thank you!


PROCEDURE PERFORMED:
Coronary angiogram stent of the right.

INDICATION:
Recurrent unstable angina, staged PCI due to renal insufficiency.

COMPLICATIONS:
None. Pre-stenosis 80 to 90, post stenosis 0. Dissection perforation,
none. ACC type C lesion due to ostial nature and calcification.

DESCRIPTION OF PROCEDURE:
After informed consent, discussion of risks and benefits, a 6-French
sheath was placed in the right common femoral artery under ultrasound
guidance. The patient was anticoagulated to a therapeutic ACT. A JR4
guide with side holes was used initially, but due to lack of support
this was changed to a 3DRC with side holes. A loose wire was used to
wire the artery. Balloon angioplasty was done with a 2.5 x 15 balloon.
Following that, a 3.5 x 18 Resolute stent was deployed at 9 atmospheres
of normal pressure. Final angiography showed excellent flow without
evidence of dissection or perforation. There were no complications.
The sheath will be pulled manually due to scar tissue. Total amount
of contrast given was 30 mL. The patient does have significant renal
insufficiency with a creatinine of 2.3. Further recommendations to
follow hospital course. The patient will be hydrated. He was given
aspirin, Effient, and Integrilin drip.


DEVICE USED: STENT CORONARY DRUG ELUTING

 

[Jim Pawloski]

Would this be a 93454 and a 92928 or just 92928? The patient was scheduled for a left heart cath but I don't see that (or a right) here. Any assistance as I am learning would be appreciated.

Thank you!


PROCEDURE PERFORMED:
Coronary angiogram stent of the right.

INDICATION:
Recurrent unstable angina, staged PCI due to renal insufficiency.

COMPLICATIONS:
None. Pre-stenosis 80 to 90, post stenosis 0. Dissection perforation,
none. ACC type C lesion due to ostial nature and calcification.

DESCRIPTION OF PROCEDURE:
After informed consent, discussion of risks and benefits, a 6-French
sheath was placed in the right common femoral artery under ultrasound
guidance. The patient was anticoagulated to a therapeutic ACT. A JR4
guide with side holes was used initially, but due to lack of support
this was changed to a 3DRC with side holes. A loose wire was used to
wire the artery. Balloon angioplasty was done with a 2.5 x 15 balloon.
Following that, a 3.5 x 18 Resolute stent was deployed at 9 atmospheres
of normal pressure. Final angiography showed excellent flow without
evidence of dissection or perforation. There were no complications.
The sheath will be pulled manually due to scar tissue. Total amount
of contrast given was 30 mL. The patient does have significant renal
insufficiency with a creatinine of 2.3. Further recommendations to
follow hospital course. The patient will be hydrated. He was given
aspirin, Effient, and Integrilin drip.


DEVICE USED: STENT CORONARY DRUG ELUTING

You have 92928-RC (C9600-RC for hospitals) since it does not look like a diagnostic exam was performed.
HTH,
Jim Pawloski, CIRCC

 

[csdarrow@hotmail.com]

92928.rc

In your documentation, under the 'indications', it says 'staged' PCI. When you see that a procedure is staged, it usually means that the patient has had a cath before and the physician is aware that he has a blockage (and where) and that needs to be fixed. Maybe they had been trying medication therapy and it was not working, etc.