bhargavi
Guru
INDICATIONS
Chest pain.
Acute myocardial infarction.
PROCEDURES
Left heart catheterization.
Coronary angiography.
Right coronary artery angioplasty.
Drug eluting stent placement.
Left anterior descending coronary artery angioplasty and drug eluting stent
placement from the right common femoral access.
DESCRIPTION OF PROCESURE
The patient was brought emergently from the Emergency Department with ongoing
chest pain and taken to the catheterization laboratory. After being places on
the catheterization laboratory table, the patient was given one milligram of
Versed and 75 milligrams of Fentanyl for her pain and sedation. Shortly
thereafter with patient on telemetric monitoring and a normal rhythm, the
patient became apneic. CPR was initiated and the patient had several minutes
of CPR and Anesthesia arrived to assist with oxygenation and ventilation.
However, she was given Narcan for reversal and became more arousable and then
had spontaneous respirations. She had return of normal sinus rhythm and
adequate blood pressure. After this stabilization, the patient was prepped and
draped in the sterile fashion. A six French sheath was placed in the right
common femoral artery. A six French diagnostic Judkins four tipped right and
left coronary catheters were then utilized for selective right and left
coronary angiography. Two critical subtotal occlusions were noted, at the
osteal segment of the large previously stented dominant right coronary artery
as well as the mid left anterior descending. It was not clear which was the
culprit lesion at this intervention and this presentation. Therefore, the
patient was given 3500 units of heparin and Integrilin double bolus and
infusion were begun. An internal mammary guiding catheter was then positioned
in the ostium of the right coronary artery and a coronary wire was advanced
distally and angioplasty and stenting were performed of the osteal and proximal
disease in the right coronary artery. This was a Boston Scientific Promus
PREMIER 3.0 by 24 millimeters stent which was deployed to high pressure and the
entire stented segment was post dilated with a 3.5 millimeters Quantum high
pressure, noncompliant balloon to high pressure to include extension of the
balloon out into the aorta to flare the ostium. The final angiographic result
was excellent with brisk TIMI Grade III flow and no residual stenosis. This
guide was then exchanged for an EBU 3.5 guiding catheter which was then
positioned into the left main coronary artery. With great difficulty a
coronary wire was advanced across the mid left anterior descending subtotal
discrete occlusion. This was a very discrete, very calcified and very tight
lesion. Multiple wires had to be utilized and in this process this vessel
actually closed temporarily. Ultimately wire access was gained. Angioplasty
was performed with a 2.25 millimeters balloon and a single Boston Scientific
Promus PREMIER drug eluting stent 2.5 by 16 millimeters was deployed and then
post dilated to high pressure. After withdrawal of the balloon, the
angiographic result was excellent with brisk TIMI Grade III distal flow and no
evidence of dissection or thrombus. The guiding catheter was then removed and
the sheath was subsequently sutured into place for arterial line monitoring
given the patient's complex presentation, multi vessel angioplasty and initial
hypotension. She was transferred to the recovery area with a systolic pressure
of 96 on Neo-Synephrine infusion 50 micrograms as well as Integrilin infusion.
ANGIOGRAPHY
The patient's angiogram revealed subtotal occlusion for a moderate length
segment from the ostium of the right coronary artery extending proximally.
Thereafter the previously placed stents in the right coronary artery were
widely patent and the distal vessel was patent, large size in distribution and
dominant. The left main was short but patent, no stenosis. The left
circumflex had 60 percent tubular narrowing unchanged in its mid segment. This
was a small distribution circumflex with one marginal. The left anterior
descending had no disease proximally, however, the mid left anterior descending
had a calcified discrete hazy appearing stenosis of 99 percent. The distal
vessel had less than 50 percent mild narrowing proximal to the apex.
Intervention as described above, successful right coronary artery and mid left
anterior descending angioplasty and drug eluting stent placement were performed.
SUMMARY AND CONCLUSIONS
1. Acute myocardial infarction presentation.
2. Acute coronary syndrome presentation.
3. Critical coronary disease with culprit lesions appearing in the osteal and
proximal segments of the large dominant right coronary artery and mid left
anterior descending, each treated with drug eluting stent placement
successfully.
4. Unchanged mild to moderate circumflex stenosis in a small circumflex.
5. Left ventricular end diastolic pressure elevated and presentation
hypotension corrected with Neo-Synephrine.
RECOMMENDATIONS
The patient has undergone multivessel angioplasty and stenting for severe
progressive coronary disease. She will be continued overnight on Integrilin
infusion, clopidogrel and aspirin duel antiplatelet therapy and close
monitoring of blood pressure with pressor support as needed. Echocardiogram is
ordered.
can i bill 93459,c9606-ld,c9606-rca or should i do c9600-rca
i am billing for facility and i saw there's only 1 mue for c9606 for hospital so i am confuse. and its acute mi.
thanks in advance
--------------------------------------------------------------------------------
Chest pain.
Acute myocardial infarction.
PROCEDURES
Left heart catheterization.
Coronary angiography.
Right coronary artery angioplasty.
Drug eluting stent placement.
Left anterior descending coronary artery angioplasty and drug eluting stent
placement from the right common femoral access.
DESCRIPTION OF PROCESURE
The patient was brought emergently from the Emergency Department with ongoing
chest pain and taken to the catheterization laboratory. After being places on
the catheterization laboratory table, the patient was given one milligram of
Versed and 75 milligrams of Fentanyl for her pain and sedation. Shortly
thereafter with patient on telemetric monitoring and a normal rhythm, the
patient became apneic. CPR was initiated and the patient had several minutes
of CPR and Anesthesia arrived to assist with oxygenation and ventilation.
However, she was given Narcan for reversal and became more arousable and then
had spontaneous respirations. She had return of normal sinus rhythm and
adequate blood pressure. After this stabilization, the patient was prepped and
draped in the sterile fashion. A six French sheath was placed in the right
common femoral artery. A six French diagnostic Judkins four tipped right and
left coronary catheters were then utilized for selective right and left
coronary angiography. Two critical subtotal occlusions were noted, at the
osteal segment of the large previously stented dominant right coronary artery
as well as the mid left anterior descending. It was not clear which was the
culprit lesion at this intervention and this presentation. Therefore, the
patient was given 3500 units of heparin and Integrilin double bolus and
infusion were begun. An internal mammary guiding catheter was then positioned
in the ostium of the right coronary artery and a coronary wire was advanced
distally and angioplasty and stenting were performed of the osteal and proximal
disease in the right coronary artery. This was a Boston Scientific Promus
PREMIER 3.0 by 24 millimeters stent which was deployed to high pressure and the
entire stented segment was post dilated with a 3.5 millimeters Quantum high
pressure, noncompliant balloon to high pressure to include extension of the
balloon out into the aorta to flare the ostium. The final angiographic result
was excellent with brisk TIMI Grade III flow and no residual stenosis. This
guide was then exchanged for an EBU 3.5 guiding catheter which was then
positioned into the left main coronary artery. With great difficulty a
coronary wire was advanced across the mid left anterior descending subtotal
discrete occlusion. This was a very discrete, very calcified and very tight
lesion. Multiple wires had to be utilized and in this process this vessel
actually closed temporarily. Ultimately wire access was gained. Angioplasty
was performed with a 2.25 millimeters balloon and a single Boston Scientific
Promus PREMIER drug eluting stent 2.5 by 16 millimeters was deployed and then
post dilated to high pressure. After withdrawal of the balloon, the
angiographic result was excellent with brisk TIMI Grade III distal flow and no
evidence of dissection or thrombus. The guiding catheter was then removed and
the sheath was subsequently sutured into place for arterial line monitoring
given the patient's complex presentation, multi vessel angioplasty and initial
hypotension. She was transferred to the recovery area with a systolic pressure
of 96 on Neo-Synephrine infusion 50 micrograms as well as Integrilin infusion.
ANGIOGRAPHY
The patient's angiogram revealed subtotal occlusion for a moderate length
segment from the ostium of the right coronary artery extending proximally.
Thereafter the previously placed stents in the right coronary artery were
widely patent and the distal vessel was patent, large size in distribution and
dominant. The left main was short but patent, no stenosis. The left
circumflex had 60 percent tubular narrowing unchanged in its mid segment. This
was a small distribution circumflex with one marginal. The left anterior
descending had no disease proximally, however, the mid left anterior descending
had a calcified discrete hazy appearing stenosis of 99 percent. The distal
vessel had less than 50 percent mild narrowing proximal to the apex.
Intervention as described above, successful right coronary artery and mid left
anterior descending angioplasty and drug eluting stent placement were performed.
SUMMARY AND CONCLUSIONS
1. Acute myocardial infarction presentation.
2. Acute coronary syndrome presentation.
3. Critical coronary disease with culprit lesions appearing in the osteal and
proximal segments of the large dominant right coronary artery and mid left
anterior descending, each treated with drug eluting stent placement
successfully.
4. Unchanged mild to moderate circumflex stenosis in a small circumflex.
5. Left ventricular end diastolic pressure elevated and presentation
hypotension corrected with Neo-Synephrine.
RECOMMENDATIONS
The patient has undergone multivessel angioplasty and stenting for severe
progressive coronary disease. She will be continued overnight on Integrilin
infusion, clopidogrel and aspirin duel antiplatelet therapy and close
monitoring of blood pressure with pressor support as needed. Echocardiogram is
ordered.
can i bill 93459,c9606-ld,c9606-rca or should i do c9600-rca
i am billing for facility and i saw there's only 1 mue for c9606 for hospital so i am confuse. and its acute mi.
thanks in advance
--------------------------------------------------------------------------------