stpat
Networker
Would this procedure require a modifier 80 since a different doc performed the IVUS and "finished up?" If so, would I put a modifer on both the 93458 and the 92978 and bill out under both docs? By the way, there is no dictation done by the second doc.
PROCEDURES PERFORMED:
1. Left heart catheterization.
2. Left ventriculography.
3. Intracoronary ultrasound of the ostial circumflex stenosis.
INDICATION FOR PROCEDURE: A 64-year-old Caucasian male with known
coronary disease, who presented with typical story for unstable angina.
Stress testing was felt to be contraindicated because of the unstable
pattern.
PROCEDURE SUMMARY: Using standard modified Seldinger technique with
fluoroscopic guidance over the right femoral head, we entered the right
femoral artery with one arterial puncture with a 21 gauge needle and
positioned a 5-French and Terumo sheath. We then advanced the 5-French
pigtail to the left ventricle and left ventriculography was performed in
the steep RAO. LV pressures recorded pre- and post-cine and pullback
pressure across the aortic valve. Catheter was then exchanged for a JL4
left diagnostic.
Advancement ________ position to the LAD was a very, almost common
ostium of the left main. We took selective pictures of the LAD in the
LAO and RAO views with cranial angulation. We were able to subselect on
one occasion with the JL4, but unsuccessful thereafter and switched to a
JL5, which gave excellent seating in the circumflex coronary branch.
Several views were obtained, particularly with steep LAO caudal views to
show the ostium of the circumflex.
The catheter was then exchanged for a JR4 right diagnostic and 3 views
were obtained in the right coronary.
At this time, we had what appeared to be a diaphragm-type lesion at the
ostium of the circumflex. There was no pressure dampening with a 5-
French catheter; however, on review with our interventional team, it was
felt that intracoronary ultrasound was indicated of this lesion.
At this time, Dr. Smith assumed control of the procedure, positioned a 6-
French sheath and advanced a standard IVUS study of the ostial lesion of
the circumflex coronary artery.
At the termination of this procedure, he performed a femoral arteriotomy
closure with Mynx device.
The patient tolerated the procedure well and no immediate complications.
RESULTS:
1. VENTRICLE: Left ventriculography revealed a normally contracting left
ventricle without areas of dyssynergy and a competent mitral valve.
LVEDP 10 mmHg. No aortic valve gradient by pullback. No significant
mitral regurgitation.
2. RIGHT CORONARY: Selective injection of the right coronary revealed a
medium size right coronary with some diffuse atherosclerotic change, but
no significant focal stenoses.
3. LEFT CORONARY: Selective injection of the left coronary revealed a
near common ostium. The LAD had one large branching septal perforator.
The LAD itself had some minor plaque throughout, but no critical
stenoses. The circumflex ostium had a diaphragm-appearing lesion
angiographically, could not be certain is was not at least a moderate
impingement. Ultrasound revealed a minor plaque and a wide open lumen at
this particular site, so no intervention was felt to be indicated.
4. VENTRICLE: Left ventriculography revealed normally contracting left
ventricle without areas of dyssynergy and a competent mitral valve.
FINAL IMPRESSION
1. Eccentric diaphragmatic lesion in the ostium of the right circumflex
with an IVUS demonstrating minimal plaque and a wide lumen.
2. Diffuse disease in a dominant right coronary without significant
focal stenoses.
3. Normal left ventriculography. Estimated ejection fraction 60%. The
left ventricular end diastolic pressure is 10 mmHg.
4. No significant aortic valve gradient by pullback or mitral
regurgitation.
RECOMMENDATIONS: Will continue with medical workup and I continue
medical therapy.
PROCEDURES PERFORMED:
1. Left heart catheterization.
2. Left ventriculography.
3. Intracoronary ultrasound of the ostial circumflex stenosis.
INDICATION FOR PROCEDURE: A 64-year-old Caucasian male with known
coronary disease, who presented with typical story for unstable angina.
Stress testing was felt to be contraindicated because of the unstable
pattern.
PROCEDURE SUMMARY: Using standard modified Seldinger technique with
fluoroscopic guidance over the right femoral head, we entered the right
femoral artery with one arterial puncture with a 21 gauge needle and
positioned a 5-French and Terumo sheath. We then advanced the 5-French
pigtail to the left ventricle and left ventriculography was performed in
the steep RAO. LV pressures recorded pre- and post-cine and pullback
pressure across the aortic valve. Catheter was then exchanged for a JL4
left diagnostic.
Advancement ________ position to the LAD was a very, almost common
ostium of the left main. We took selective pictures of the LAD in the
LAO and RAO views with cranial angulation. We were able to subselect on
one occasion with the JL4, but unsuccessful thereafter and switched to a
JL5, which gave excellent seating in the circumflex coronary branch.
Several views were obtained, particularly with steep LAO caudal views to
show the ostium of the circumflex.
The catheter was then exchanged for a JR4 right diagnostic and 3 views
were obtained in the right coronary.
At this time, we had what appeared to be a diaphragm-type lesion at the
ostium of the circumflex. There was no pressure dampening with a 5-
French catheter; however, on review with our interventional team, it was
felt that intracoronary ultrasound was indicated of this lesion.
At this time, Dr. Smith assumed control of the procedure, positioned a 6-
French sheath and advanced a standard IVUS study of the ostial lesion of
the circumflex coronary artery.
At the termination of this procedure, he performed a femoral arteriotomy
closure with Mynx device.
The patient tolerated the procedure well and no immediate complications.
RESULTS:
1. VENTRICLE: Left ventriculography revealed a normally contracting left
ventricle without areas of dyssynergy and a competent mitral valve.
LVEDP 10 mmHg. No aortic valve gradient by pullback. No significant
mitral regurgitation.
2. RIGHT CORONARY: Selective injection of the right coronary revealed a
medium size right coronary with some diffuse atherosclerotic change, but
no significant focal stenoses.
3. LEFT CORONARY: Selective injection of the left coronary revealed a
near common ostium. The LAD had one large branching septal perforator.
The LAD itself had some minor plaque throughout, but no critical
stenoses. The circumflex ostium had a diaphragm-appearing lesion
angiographically, could not be certain is was not at least a moderate
impingement. Ultrasound revealed a minor plaque and a wide open lumen at
this particular site, so no intervention was felt to be indicated.
4. VENTRICLE: Left ventriculography revealed normally contracting left
ventricle without areas of dyssynergy and a competent mitral valve.
FINAL IMPRESSION
1. Eccentric diaphragmatic lesion in the ostium of the right circumflex
with an IVUS demonstrating minimal plaque and a wide lumen.
2. Diffuse disease in a dominant right coronary without significant
focal stenoses.
3. Normal left ventriculography. Estimated ejection fraction 60%. The
left ventricular end diastolic pressure is 10 mmHg.
4. No significant aortic valve gradient by pullback or mitral
regurgitation.
RECOMMENDATIONS: Will continue with medical workup and I continue
medical therapy.
