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Can someone please help me code this with correct modifiers for BCBS insurance?
INTERPRETATION: The patient underwent stenting of a subtotally occluded proximal LAD 2 hrs prior to complaining of severe neck pain radiating to the upper chest. A stat 12-lead EKG revealed evidence of ST elevations involving the anteroseptal and lateral leads consistent with acute stent thrombosis.
DESCRIPTION OF PROCEDURE: The patient was brough back emergently to the cardiac catheterization labroatory. The left groin was prepped and draped in the usual manner. It was anesthetized with 1% lidocaine. A 6-French sheath was placed in the left femoral artery using a modified Seldinger technique. Coronary angiography was performed using 6-French JL4 guide catheter. This revealed evidence of occlusion of the LAD right at the stent.
Heparin bolus and Integrillin double bolus and drip were started immediately. I attempted twice a 0.014 BMW wire and 0.014 Whisper wire to cross the LAD. I was able to get across the LAD. On two occasions; however, I was unable to get a balloon to cross the stent, suggesting that the wire went into the most proximal strut of the stent rather than being 100% intraluminal. With wire advancement, there was definite improvement of flow along the vessel TIMI grade I and then II. I repositioned the Whisper extra support wire and I was able to easily get a 2.5 x 12mm Trek balloon into the stent without difficulty indicating that the wire went through the stent without going through any of the struts. The balloon was used to dilate the area within the sstent at 10 atmospheres. Repeat angiography revealed evidence of significant thrombus burden within the stent and a little bit beyond. An angiojet catheter was then used with multiple pases to eliminate the thrombus. Intracoronary nitroglycerin and intracoronary Cardizem were used to improve to minimize spasm. A repeat angiography at this point reealed evidence for wide patency of the LAD with TIMI grade III flow and a gradual elimination of any thrombus within the LAD. There was some residual thrombus within the first and second diagonal vessel: however, there was no flow-limiting and the flow was continuing to improe in these vessels with resolution of ST elevation in leads I and AVL and resolution of any neck or chest discomfort. Angiography in mulitiple views with and without wire revealed no eveidence of any dissection or staining. After thrombus resolution, I dilated the most proximal 8mm of the 15mm stent with a 3.5x8 mm Trek balloon at 10 atmospheres. I did not feel comfortable dilating the rest of the stent with that baloon since the vessel is much smaller further downstream. Final angiography regealed evidence of no residual stenosis within the stent with no dissection, thrombus or stain and there was excellent TIMI grade III flow along the vessel. The first and second diagnol vessels had 70% and 90% ostial stenosis with some thrombus, which appeared to be improving and there was TIMI grade III flow along both vessels with no residual ST elevation side, so I left them alone.
ACT at the end of the procedure was 181, so the sheath was removeed and hemostasis of the elft groin was achieved using the mynx device. The integrilin drip was continued.
INTERPRETATION: The patient underwent stenting of a subtotally occluded proximal LAD 2 hrs prior to complaining of severe neck pain radiating to the upper chest. A stat 12-lead EKG revealed evidence of ST elevations involving the anteroseptal and lateral leads consistent with acute stent thrombosis.
DESCRIPTION OF PROCEDURE: The patient was brough back emergently to the cardiac catheterization labroatory. The left groin was prepped and draped in the usual manner. It was anesthetized with 1% lidocaine. A 6-French sheath was placed in the left femoral artery using a modified Seldinger technique. Coronary angiography was performed using 6-French JL4 guide catheter. This revealed evidence of occlusion of the LAD right at the stent.
Heparin bolus and Integrillin double bolus and drip were started immediately. I attempted twice a 0.014 BMW wire and 0.014 Whisper wire to cross the LAD. I was able to get across the LAD. On two occasions; however, I was unable to get a balloon to cross the stent, suggesting that the wire went into the most proximal strut of the stent rather than being 100% intraluminal. With wire advancement, there was definite improvement of flow along the vessel TIMI grade I and then II. I repositioned the Whisper extra support wire and I was able to easily get a 2.5 x 12mm Trek balloon into the stent without difficulty indicating that the wire went through the stent without going through any of the struts. The balloon was used to dilate the area within the sstent at 10 atmospheres. Repeat angiography revealed evidence of significant thrombus burden within the stent and a little bit beyond. An angiojet catheter was then used with multiple pases to eliminate the thrombus. Intracoronary nitroglycerin and intracoronary Cardizem were used to improve to minimize spasm. A repeat angiography at this point reealed evidence for wide patency of the LAD with TIMI grade III flow and a gradual elimination of any thrombus within the LAD. There was some residual thrombus within the first and second diagonal vessel: however, there was no flow-limiting and the flow was continuing to improe in these vessels with resolution of ST elevation in leads I and AVL and resolution of any neck or chest discomfort. Angiography in mulitiple views with and without wire revealed no eveidence of any dissection or staining. After thrombus resolution, I dilated the most proximal 8mm of the 15mm stent with a 3.5x8 mm Trek balloon at 10 atmospheres. I did not feel comfortable dilating the rest of the stent with that baloon since the vessel is much smaller further downstream. Final angiography regealed evidence of no residual stenosis within the stent with no dissection, thrombus or stain and there was excellent TIMI grade III flow along the vessel. The first and second diagnol vessels had 70% and 90% ostial stenosis with some thrombus, which appeared to be improving and there was TIMI grade III flow along both vessels with no residual ST elevation side, so I left them alone.
ACT at the end of the procedure was 181, so the sheath was removeed and hemostasis of the elft groin was achieved using the mynx device. The integrilin drip was continued.
