I'm a little bit confused, since there is mention of the angiography however the actual findings of everything viewed and pressures (stenosis, patency, etc) is not provided. Since this is a right atrial mass..right atrium would be right side of the heart, it would make more since that they performed coronary angiography and heart catheterization (right side, original access gained through right femoral vein), if so then you would then be able to report from code range 93454-93461 (likely 93456), which CPT 92973 can be reported with. CPT 92973 can't be reported by itself. (Also, there is no mention of aspiration thrombectomy in the documentation, only mechanical). Going based off of what's documented, you'd report right femoral angiography, that would be CPT 75710 which isn't supported as primary code for CPT 92973, in that case you would have to report that as the unlisted code. If you're able to clarify with the physician (preferably an amendment added), that would be good. This report is lacking a lot of description when it comes to the angiography, and even the mechanical thrombectomy, it's basically only stated that it was performed, however the procedure itself is not described much, if at all.
I totally agree that the documentation is lacking. We do have a nursing procedure log that we also use but not able to share much of it here accept this info below. I appreciate any help. Thanks.
Surface ultrasound used for vascular access. Imaging obtained and stored in current
cardiovascular PACS.
4/26/2021 17:19:36 Percutaneous stick to the right radial artery per - Dr.
4/26/2021 17:20:44 Access: Sheath was inserted into the right radial artery - 5-6F 10cm Glidesheath Slender
4/26/2021 17:21:56 Sentinel cerebral protection system inserted over the wire.
4/26/2021 17:21:56 Sentinel distal embolic filter delivered to the left common carotid artery.
4/26/2021 17:21:56 Sentinel proximal embolic filter delivered to the brachiocephalic artery.
4/26/2021 17:22:00 HR: 80, DURING, NIBP: 101 / 64, LOC: 0 , LOP: 0 , RESP: 23, SPO2: 99, NOTES: Sinus Rhythm
4/26/2021 17:26:54 HR: 83, DURING, NIBP: 104 / 61, LOC: 0 , LOP: 0 , RESP: 22, SPO2: 97, NOTES: Sinus Rhythm
4/26/2021 17:28:14 Local anesthetic to right groin region with 2% lidocaine SQ, total injected 5 mls
4/26/2021 17:29:39 Venous access: Sheath was inserted into the right common femoral vein - 4F 10cm Mini Stick
Max micro introducer catheter
4/26/2021 17:29:53 Venous access: Sheath was exchanged into the right femoral vein - 8F 10cm Pinnacle Sheath
4/26/2021 17:30:00 Venous access: Perclose preclosure of the right common femoral vein performed by dr and dr
4/26/2021 17:30:27 Venous access: Sheath was exchanged into the right femoral vein - 24F 33cm Gore Dry Seal
Sheath after 16 and 20 f dilators
4/26/2021 17:31:27 Guide wire advanced -
4/26/2021 17:31:48 HR: 81, DURING, NIBP: 103 / 64, LOC: 0 , LOP: 0 , RESP: 16, SPO2: 97, NOTES: Sinus Rhythm
4/26/2021 17:32:54 {Procedure} Ultrasound- TTE (Transthoracic Echocardiogram)
4/26/2021 17:33:02 Support catheter introduced over the wire - - .035 / 135cm Angled Navicross Support Catheter
4/26/2021 17:34:00 Guide wire advanced - - Amplatz super stiff wire 0.035 x 260cm 1 cm tip
4/26/2021 17:34:39 Thrombectomy catheter introduced over the wire. - INARI MEDICAL 24F 90CM FLOWTRIEVER
ASPIRATION GUIDE CATH
4/26/2021 17:34:49 {GUIDING CATH INARI} INARI MEDICAL 24F 90CM FLOWTRIEVER ASPIRATION GUIDE
CATH - Qty: 1 Each Part #: 11820265 Lot #: 21010010
4/26/2021 17:36:43 HR: 84, DURING, NIBP: 103 / 65, LOC: 0 , LOP: 0 , RESP: 9, SPO2: 99, NOTES: Sinus Rhythm
4/26/2021 17:40:15 TTE -imaging in progress By Dr .
4/26/2021 17:41:37 HR: 85, DURING, NIBP: 98 / 61, LOC: 0 , LOP: 0 , RESP: 15, SPO2: 97, NOTES: Sinus Rhythm
4/26/2021 17:43:36 Thrombectomy catheter aspiration volume= 60 mls
specimen collected and sent with pathology orders
4/26/2021 17:46:31 HR: 84, DURING, NIBP: 99 / 64, LOC: 0 , LOP: 0 , RESP: 15, SPO2: 98, NOTES: Sinus Rhythm
4/26/2021 17:50:35 Catheter removed.
4/26/2021 17:50:46 device removed.
4/26/2021 17:51:02 Sentinel proximal embolic filter recaptured into the delivery catheter .
4/26/2021 17:51:02 Sentinel distal embolic filter recaptured into the delivery catheter.
4/26/2021 17:51:02 Sentinel cerebral protection system removed.
4/26/2021 17:51:25 HR: 74, DURING, NIBP: 102 / 61, LOC: 0 , LOP: 0 , RESP: 10, SPO2: 99, NOTES: Sinus Rhythm
4/26/2021 17:53:32 Sheath(s)- pulled . Previously placed perclose to the right common femoral vein completed by Dr
, manual pressure held for 5 mins
4/26/2021 17:53:49 Closure Method: #1: successful Device ID: 9-Perclose ProGlide
4/26/2021 17:53:53 Sheath(s)- Radial sheath pulled. Radial band used, inflated with 10 mls of air
4/26/2021 17:53:57 Closure Method: #2: successful Device ID: 2-Mechanical Compression
4/26/2021 17:53:58 Drape removed, procedure completed