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How would you bill this procedure to Medicare Thanks
INDICATIONS: Angina pectoris, congestive heart failure.
PROCEDURE: Left heart catheterization with selective coronary angiography, bypass graft angiography with percutaneous intervention of the distal left main and proximal left circumflex with a single Resolute drug-eluting stent
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old with severe morbid obesity, hypertension, diabetes, dyslipidemia, CKD and severe coronary disease, previous bypass graft x4 with LIMA to LAD, vein graft to diagonal, vein graft to sequential RCA
RPDA with an ischemic cardiomyopathy who underwent complex percutaneous intervention approximately 1 year ago reconstructing his left circumflex distribution when he was found to only have 1 patent bypass graft. He had been doing well, however,
developed progressive heart failure and typical angina with class 4 anginal symptoms despite acceleration and maximization of medical therapy. As such, he was referred for diagnostic angiography with class IV symptoms.
PROCEDURE: Informed consent was obtained, the patient understood the risks, benefits and alternatives procedure and agreed to proceed with the procedure. The right groin was prepped in the usual sterile fashion and 2% lidocaine infused subcutaneously
until adequate anesthesia was obtained. Right common femoral artery accessed using modified Seldinger technique of which a 6 French 45 cm long sheath was placed without complication. Patient has extensive iliac tortuosity precluding catheter
manipulation and therefore a long sheath was elected. The diagnostic JL5 diagnostic catheter and a JR4 as well as an IMA catheter was used to perform selective coronary angiography and left heart catheterization as well as bypass graft angiography. At
the conclusion of the procedure, an Angio-Seal device was deployed without complication.
HEMODYNAMICS: Left ventricular end-diastolic pressure measured 25 mmHg. There was a mild 10 mm transaortic gradient upon pullback.
LEFT VENTRICULOGRAPHY: Deferred due to patient's mildly elevated creatinine.
CORONARY ANGIOGRAPHY:
LEFT MAIN: Moderate disease with approximately 70% distal left main restenosis.
LAD: Totally occluded at its ostium, however reconstituted after the touchdown of a patent bypass graft. There was moderate diffuse distal disease. There was a prominent first diagonal being seen filled from a retrograde fashion from a patent IMA
however, there was an 80% ostial stenosis of its diagonal. There is no patent bypass graft to this diagonal. The IMA was extremely tortuous.
LEFT CIRCUMFLEX: Gave off 2 large marginal branches. There was approximately a 90% tubular in-stent restenosis class B2 lesion seen in the proximal portion. There is patent stent seen extending into the first marginal as well into the second marginal
with moderate diffuse distal disease.
RCA: Totally occluded proximally. It was small in caliber. Vein graft to the diagonal and RCA, PDA were noted to be totally occluded. Selective engagement of the IMA demonstrating significant tortuosity; however, no occult stenosis at the anastomosis
or within the vessel.
SUMMARY: Severe restenosis of the distal left main and proximal left circumflex. Residual ostial diagonal lesion with known totally occluded bypass graft.
Given the patient's clinical presentation, it is likely his symptoms are secondary to his restenosis and therefore percutaneous intervention was decided.
INTERVENTION: Angiomax was used for effective anticoagulation and EBU 4.0 guide catheter was used to intubate the left main coronary artery. A Runthrough wire was placed to the distal second marginal a 2.5x15 balloon was used to predilate the lesion.
A 2.75x30 Resolute drug-eluting stent was used to cover both lesions and was postdilated with a 3.0 noncompliant balloon to 22 atmospheres with an excellent angiographic result.
SUMMARY: Successful percutaneous intervention of sequential lesions in the distal left main and proximal left circumflex with Resolute drug-eluting stent.
CLINICAL PATHWAY: We hope this will afford him symptomatic improvement and improve his diastolic dysfunction likely contributing to his congestive heart failure as well as his angina. We will continue with current medical therapy and monitor for
symptoms. Should he have residual symptoms complex intervention to revascularize the first diagonal in a retrograde fashion from the bypass grafts could be entertained. We thank you for the opportunity to participate in the care of this fine gentleman.
I have 93459-26-59
92928-LC
is there any other codes and why
INDICATIONS: Angina pectoris, congestive heart failure.
PROCEDURE: Left heart catheterization with selective coronary angiography, bypass graft angiography with percutaneous intervention of the distal left main and proximal left circumflex with a single Resolute drug-eluting stent
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old with severe morbid obesity, hypertension, diabetes, dyslipidemia, CKD and severe coronary disease, previous bypass graft x4 with LIMA to LAD, vein graft to diagonal, vein graft to sequential RCA
RPDA with an ischemic cardiomyopathy who underwent complex percutaneous intervention approximately 1 year ago reconstructing his left circumflex distribution when he was found to only have 1 patent bypass graft. He had been doing well, however,
developed progressive heart failure and typical angina with class 4 anginal symptoms despite acceleration and maximization of medical therapy. As such, he was referred for diagnostic angiography with class IV symptoms.
PROCEDURE: Informed consent was obtained, the patient understood the risks, benefits and alternatives procedure and agreed to proceed with the procedure. The right groin was prepped in the usual sterile fashion and 2% lidocaine infused subcutaneously
until adequate anesthesia was obtained. Right common femoral artery accessed using modified Seldinger technique of which a 6 French 45 cm long sheath was placed without complication. Patient has extensive iliac tortuosity precluding catheter
manipulation and therefore a long sheath was elected. The diagnostic JL5 diagnostic catheter and a JR4 as well as an IMA catheter was used to perform selective coronary angiography and left heart catheterization as well as bypass graft angiography. At
the conclusion of the procedure, an Angio-Seal device was deployed without complication.
HEMODYNAMICS: Left ventricular end-diastolic pressure measured 25 mmHg. There was a mild 10 mm transaortic gradient upon pullback.
LEFT VENTRICULOGRAPHY: Deferred due to patient's mildly elevated creatinine.
CORONARY ANGIOGRAPHY:
LEFT MAIN: Moderate disease with approximately 70% distal left main restenosis.
LAD: Totally occluded at its ostium, however reconstituted after the touchdown of a patent bypass graft. There was moderate diffuse distal disease. There was a prominent first diagonal being seen filled from a retrograde fashion from a patent IMA
however, there was an 80% ostial stenosis of its diagonal. There is no patent bypass graft to this diagonal. The IMA was extremely tortuous.
LEFT CIRCUMFLEX: Gave off 2 large marginal branches. There was approximately a 90% tubular in-stent restenosis class B2 lesion seen in the proximal portion. There is patent stent seen extending into the first marginal as well into the second marginal
with moderate diffuse distal disease.
RCA: Totally occluded proximally. It was small in caliber. Vein graft to the diagonal and RCA, PDA were noted to be totally occluded. Selective engagement of the IMA demonstrating significant tortuosity; however, no occult stenosis at the anastomosis
or within the vessel.
SUMMARY: Severe restenosis of the distal left main and proximal left circumflex. Residual ostial diagonal lesion with known totally occluded bypass graft.
Given the patient's clinical presentation, it is likely his symptoms are secondary to his restenosis and therefore percutaneous intervention was decided.
INTERVENTION: Angiomax was used for effective anticoagulation and EBU 4.0 guide catheter was used to intubate the left main coronary artery. A Runthrough wire was placed to the distal second marginal a 2.5x15 balloon was used to predilate the lesion.
A 2.75x30 Resolute drug-eluting stent was used to cover both lesions and was postdilated with a 3.0 noncompliant balloon to 22 atmospheres with an excellent angiographic result.
SUMMARY: Successful percutaneous intervention of sequential lesions in the distal left main and proximal left circumflex with Resolute drug-eluting stent.
CLINICAL PATHWAY: We hope this will afford him symptomatic improvement and improve his diastolic dysfunction likely contributing to his congestive heart failure as well as his angina. We will continue with current medical therapy and monitor for
symptoms. Should he have residual symptoms complex intervention to revascularize the first diagonal in a retrograde fashion from the bypass grafts could be entertained. We thank you for the opportunity to participate in the care of this fine gentleman.
I have 93459-26-59
92928-LC
is there any other codes and why