bhargavi
Guru
Pre-procedure Diagnosis
Unspecified cardiovascular disease [I25.10]
Link to Procedure Log
Procedure Log
Post-procedure Diagnosis
TR
Indications
Unspecified cardiovascular disease [I25.10 (ICD-10-CM)]
Essential hypertension, malignant [I10 (ICD-10-CM)]
Apolipoprotein E deficiency [E78.2 (ICD-10-CM)]
Conclusion
After obtaining informed consent, the patient was prepped and draped in sterile fashion. Approximately 10 mL 2% lidocaine anesthesia was administered to the right groin prior to placement of the arterial and venous sheath. Under fluoroscopic guidance and using modified Seldinger technique, a 6 French arterial sheath was placed without difficulty into the right femoral artery. We initially decided to proceed with percutaneous intervention and obtained a 6 French JL4 guide catheter which was positioned into the left main coronary artery. Selective injection of the left coronary system revealed reocclusion of the left circumflex likely. Diffuse restenosis of the previously placed stents in January 2017. We attempted to cross through the area of reocclusion utilizing first 0.014 inch Asahi per water straight wire but were unsuccessful in getting into the distal portion of the vessel. We then obtained a whisper wire and had similar difficulty. There was a hinge point within the midportion of the stents where, although the wire couldn't pass, we could never successfully pass a balloon. I suspect that the wire was underneath stent struts and could never be directed back into the true lumen of the vessel to allow for balloon angioplasty. After making attempts for nearly one hour to successfully wired the vessel, we ultimately decided to abort his portion of the procedure. The distal portion of the obtuse marginal branch did fill via left to left and right to left collaterals and appear to be large enough for bypass grafting.
*
We decided at this point to repeat the remainder of the coronary angiogram including the left heart catheterization, coronary angiography, nonselective injection of the left internal mammary artery and nonselective injection of the right femoral artery using hand injections of Omnipaque contrast via 6 French JL4 guide and FR4 diagnostic catheters. The remaining findings are as follows:
*
The left ventricular pressure was 151/12 mmHg. The aortic pressure was 151/65 mmHg.
*
Left Main: The left main is a large vessel which bifurcates into left anterior descending and left circumflex branches. It is short but free of disease.
*
Left anterior descending: The left anterior descending is a moderately large vessel which wraps the coronary apex and gives rise to 2 major diagonal branches of significance. In the proximal left anterior descending, just beyond the origin of the major diagonal branch, there is a tubular 50% stenosis. In the mid vessel, just beyond the septal perforating branch, there is a second area of approximate 70% stenosis followed by an additional area of tubular 60-70% stenosis within tortuosity in the mid and distal left anterior descending. The first diagonal branch is moderate to large in caliber and has proximal 30-40% disease. The second diagonal branch is moderate in caliber and has proximal to mid 70-75% stenosis. It is of borderline size for bypass grafting.
*
Left circumflex: The left circumflex is a moderate sized anatomically nondominant vessel which gives rise to one major obtuse marginal branches of significance. Stents are visualized extending throughout the proximal left circumflex into the main portion of the obtuse marginal branch. Unfortunately, there is occlusion within the central portion of the stented segment with left to left and right-to-left collaterals to a moderate to large distribution and moderate sized obtuse marginal vessel.
*
Right coronary artery: The right coronary artery is a large anatomically dominant vessel which gives rise to a moderate-sized posterior descending and posterolateral arcade. There appears to be progression of disease in the mid right coronary artery to 70%. The posterior descending branch is small to medium in caliber and has ostial proximal 60-70% disease. The posterolateral branch is moderate in caliber and free of disease.
*
Active injection of the left internal mammary artery via the left subclavian revealed it to be large and widely patent with excellent runoff.
*
Left ventriculogram: Left ventriculography was not performed due to contrast utilized during the procedure.
*
Nonselective injection of the right femoral artery revealed position of the arterial sheath in the very proximal common femoral artery above the bifurcation. There was no evidence of angiographic disease at the site of sheath insertion. As such, a 6 French Angio-Seal was placed without difficulty.
*
The patient was then transferred to the recovery area in stable condition:
*
Impression:
*
1. Reocclusion of previously stented left circumflex from January 2017.
2. Severe mid left anterior descending and second diagonal disease.
3. Progression of RCA disease in the severe range.
4. Status post unsuccessful attempt at recanalization and repeat stenting of the left circumflex.
5. Patent IMA.
6. Normal intracardiac hemodynamics.
7. Status post Angio-Seal placement.
*
Plan:
*
1. Refer for coronary bypass to include LIMA to LAD, vein graft to RCA, vein graft to OM, and possibly vein graft to second diagonal branch
should I just code 93459 or also 92920-52?
thanks in advance
Unspecified cardiovascular disease [I25.10]
Link to Procedure Log
Procedure Log
Post-procedure Diagnosis
TR
Indications
Unspecified cardiovascular disease [I25.10 (ICD-10-CM)]
Essential hypertension, malignant [I10 (ICD-10-CM)]
Apolipoprotein E deficiency [E78.2 (ICD-10-CM)]
Conclusion
After obtaining informed consent, the patient was prepped and draped in sterile fashion. Approximately 10 mL 2% lidocaine anesthesia was administered to the right groin prior to placement of the arterial and venous sheath. Under fluoroscopic guidance and using modified Seldinger technique, a 6 French arterial sheath was placed without difficulty into the right femoral artery. We initially decided to proceed with percutaneous intervention and obtained a 6 French JL4 guide catheter which was positioned into the left main coronary artery. Selective injection of the left coronary system revealed reocclusion of the left circumflex likely. Diffuse restenosis of the previously placed stents in January 2017. We attempted to cross through the area of reocclusion utilizing first 0.014 inch Asahi per water straight wire but were unsuccessful in getting into the distal portion of the vessel. We then obtained a whisper wire and had similar difficulty. There was a hinge point within the midportion of the stents where, although the wire couldn't pass, we could never successfully pass a balloon. I suspect that the wire was underneath stent struts and could never be directed back into the true lumen of the vessel to allow for balloon angioplasty. After making attempts for nearly one hour to successfully wired the vessel, we ultimately decided to abort his portion of the procedure. The distal portion of the obtuse marginal branch did fill via left to left and right to left collaterals and appear to be large enough for bypass grafting.
*
We decided at this point to repeat the remainder of the coronary angiogram including the left heart catheterization, coronary angiography, nonselective injection of the left internal mammary artery and nonselective injection of the right femoral artery using hand injections of Omnipaque contrast via 6 French JL4 guide and FR4 diagnostic catheters. The remaining findings are as follows:
*
The left ventricular pressure was 151/12 mmHg. The aortic pressure was 151/65 mmHg.
*
Left Main: The left main is a large vessel which bifurcates into left anterior descending and left circumflex branches. It is short but free of disease.
*
Left anterior descending: The left anterior descending is a moderately large vessel which wraps the coronary apex and gives rise to 2 major diagonal branches of significance. In the proximal left anterior descending, just beyond the origin of the major diagonal branch, there is a tubular 50% stenosis. In the mid vessel, just beyond the septal perforating branch, there is a second area of approximate 70% stenosis followed by an additional area of tubular 60-70% stenosis within tortuosity in the mid and distal left anterior descending. The first diagonal branch is moderate to large in caliber and has proximal 30-40% disease. The second diagonal branch is moderate in caliber and has proximal to mid 70-75% stenosis. It is of borderline size for bypass grafting.
*
Left circumflex: The left circumflex is a moderate sized anatomically nondominant vessel which gives rise to one major obtuse marginal branches of significance. Stents are visualized extending throughout the proximal left circumflex into the main portion of the obtuse marginal branch. Unfortunately, there is occlusion within the central portion of the stented segment with left to left and right-to-left collaterals to a moderate to large distribution and moderate sized obtuse marginal vessel.
*
Right coronary artery: The right coronary artery is a large anatomically dominant vessel which gives rise to a moderate-sized posterior descending and posterolateral arcade. There appears to be progression of disease in the mid right coronary artery to 70%. The posterior descending branch is small to medium in caliber and has ostial proximal 60-70% disease. The posterolateral branch is moderate in caliber and free of disease.
*
Active injection of the left internal mammary artery via the left subclavian revealed it to be large and widely patent with excellent runoff.
*
Left ventriculogram: Left ventriculography was not performed due to contrast utilized during the procedure.
*
Nonselective injection of the right femoral artery revealed position of the arterial sheath in the very proximal common femoral artery above the bifurcation. There was no evidence of angiographic disease at the site of sheath insertion. As such, a 6 French Angio-Seal was placed without difficulty.
*
The patient was then transferred to the recovery area in stable condition:
*
Impression:
*
1. Reocclusion of previously stented left circumflex from January 2017.
2. Severe mid left anterior descending and second diagonal disease.
3. Progression of RCA disease in the severe range.
4. Status post unsuccessful attempt at recanalization and repeat stenting of the left circumflex.
5. Patent IMA.
6. Normal intracardiac hemodynamics.
7. Status post Angio-Seal placement.
*
Plan:
*
1. Refer for coronary bypass to include LIMA to LAD, vein graft to RCA, vein graft to OM, and possibly vein graft to second diagonal branch
should I just code 93459 or also 92920-52?
thanks in advance