Jane5711
Networker
Hi,
Stuck again.
I was going to code just 93459,26 and sedation but what about the Sel. Rt Brachiocephalic angiography???? Is this included in the 93459, 26 or can this be coded? 93455,26?
PROCEDURES PERFORMED:
1. Left heart cardiac catheterization.
2. Selective coronary artery angiography.
3. Left ventriculography.
4. Selective left internal mammary artery angiography and left
subclavian vein artery angiography.
5. Selective right brachiocephalic artery angiography and right
internal mammary artery angiography.
6. Intravenous conscious sedation using 1 mg of Versed and 3 mg of
morphine for a total of conscious sedation time of about 36 minutes.
INDICATIONS:
1. Coronary artery disease with history of angioplasty and stent to the
ostial proximal LAD and mid LAD in August 2017 with a previous
history of stent in the right coronary artery and significant
high-grade lesion in the first obtuse marginal branch of the left
circumflex artery with 80 percent stenosis, 75 percent of the mid
right coronary artery.
2. Previous history of coronary artery angioplasty and stent, the last
stent on 08/08/2017 to the ostial proximal LAD 3.5/18 mm Xience
stent and in the a mid LAD with a 2.5/18 mm Xience stent.
3. Hypertension and hypertensive heart disease.
4. Diabetes mellitus.
5. Previous history of ischemic heart disease and recurrent angina
pectoris.
PROCEDURE IN DETAIL: After the informed consent was obtained, the patient
was prepped and draped in the usual sterile fashion. Two percent lidocaine
was used for local anesthesia in the right groin. Vascular access was
obtained in the right femoral artery and over a guide wire 6-French
angiographic sheath was placed in the right femoral artery.
Over a guidewire, 6-French XB 3.5 guide without side holes was used to
engage the left coronary artery. The left coronary angiography was
performed.
Then, a 6-French JR4 catheter was used to selectively engage the right
coronary artery and selective right coronary artery angiography was
performed.
A 6-French _____ catheter was used to selectively engage the left
subclavian artery. Selective left subclavian artery to visualize the left
internal mammary artery was performed. Left subclavian artery angiography
and left internal mammary artery angiographies were performed.
A 6-French JR4 catheter was used to selectively engage the right
brachiocephalic artery and right brachiocephalic artery angiography to
visualize the right internal mammary artery was performed.
Then, a 6-French pigtail catheter was introduced through the guidewire in
the left ventricle. Left ventricular hemodynamics were measured and left
ventriculography in the RAO projection was performed. The pigtail catheter
was removed under hemodynamic monitoring from the left ventricle to the
aorta.
At the end of the diagnostic cardiac catheterization, the guidewire and
diagnostic catheters were removed. Arterial sheath was sutured in place
and the patient was transferred in a stable condition to the floor for
further care with no complications. The pigtail catheter was removed under
hemodynamic monitoring from the left ventricle to the aorta.
COMPLICATIONS: None.
FINDINGS:
HEMODYNAMIC DATA:
1. Aortic pressure 123/74/96 mm mean.
2. Heart rate 74 beats per minute.
3. Left ventricular pressure of 122/3/18 mm.
ANATOMIC FINDINGS:
LEFT VENTRICULOGRAPHY:
1. Left ventricle appears to be mildly dilated.
2. Anterobasal, moderate-to-severe hypokinesis.
3. Anterolateral, severe hypokinesis.
4. Apical, severe hypokinesis.
5. Inferior normal.
6. Posterobasal normal.
7. Left ventricular ejection fraction is approximately 25 to 30 percent
by visual estimate with no significant gradient across the aortic
valve noted, 1 to 2 plus mitral insufficiency noted.
CORONARY DATA:
1. Heavy calcification noted in the mid LAD and mid left circumflex
artery and the mid right coronary artery.
2. LEFT MAIN CORONARY ARTERY: The left main coronary artery has no
high grade focal stenosis. It divides into left anterior descending
artery and left circumflex artery. It is a moderate caliber vessel.
It also gives rise to the small ramus intermedius artery. Left main
coronary artery is a moderate caliber vessel. It has no high grade
focal stenosis. It divides into left anterior descending artery,
left circumflex artery, and a small ramus intermedius artery.
3. LEFT ANTERIOR DESCENDING ARTERY: The left anterior descending
artery is totally occluded within the stent and in its proximal
portion. The entire LAD is not visualized with antegrade flow, but
the mid and distal LAD is noted to fill via retrograde collaterals
from right to left and it is a small caliber vessel. It seems to
have occlusion in the mid portion within the stent also.
Left anterior descending was previously known to have 2 diagonal
branches. The first diagonal branch is a small vessel. The second
diagonal branch is a small-caliber vessel with a high-grade 90
percent stenosis in the mid portion of the second diagonal branch.
The entire mid distal LAD was a small caliber vessel, was a
trans-apical vessel, as was visualized previously and also now seen
faintly via the collaterals.
4. LEFT CIRCUMFLEX ARTERY: The left circumflex artery is a
moderate-caliber vessel in the proximal portion, maximum 90 degree
bend in the early proximal portion with moderate disease and
possibly moderate stenosis of 60 percent with calcification. The
proximal left circumflex artery gives rise to a small obtuse
marginal branch, distally diseased. The left saphenous artery has
mild-moderate calcification with an eccentric 50-60 percent stenosis
distal to this. The left circumflex artery gives rise to a small AV
circumflex artery. The distal left circumflex artery bifurcates in
to 2 obtuse marginal branches and into the second and third obtuse
marginal branches.
The second obtuse marginal branch is a 2.25 mm caliber vessel with
the proximal 80 percent stenosis followed by another 80 percent
stenosis in the distal portion.
The third obtuse marginal branch is a medium-caliber vessel,
tortuous in its course with mild disease.
5. RIGHT CORONARY ARTERY: Right coronary artery is a large dominant
vessel. Proximal right coronary artery has a calcific 50 percent
stenosis at the first vein.
Mid right coronary artery is a patent stent with a 20 to 30 percent
focal in-stent stenosis and mild 20 percent diffuse in-stent
stenosis.
At the distal edge of the stent, the right coronary artery has a
focal 40 percent stenosis.
Just after the second main, the right coronary artery has a hazy
diffuse calcific 70-75 percent stenosis.
Distal to this, the right coronary artery bifurcates into the
posterior descending branch and a posterolateral branch.
The posterior descending branch is a medium-caliber vessel with mild
disease.
The posterolateral branch gives rise to 4 other small posterolateral
branches and is a medium-caliber vessel with mild disease.
6. LEFT SUBCLAVIAN ARTERY: The left subclavian artery has no
significant disease. It gives rise to the left internal mammary
artery. The left internal mammary artery is a medium-caliber vessel
without significant disease.
7. RIGHT BRACHIOCEPHALIC ARTERY: Right brachiocephalic artery has no
significant disease. It gives rise to right internal mammary artery.
The right internal mammary artery has no significant disease.
IMPRESSION:
1. Severe 3-vessel coronary artery disease with a total occlusion of
the proximal left anterior descending with in-stent restenosis as
well as likely mid left anterior descending stent as noted by
collaterals from right to left; eccentric 60 percent calcific
stenosis of the early mid left circumflex artery; second obtuse
marginal branch with 2 sequential lesions of 80 and 80 percent
stenosis in the mid and distal portion; right coronary artery with a
50 percent proximal stenosis, patent stent in the midportion, focal
30 percent in-stent restenosis; 40 percent stenosis of the distal
edge of the stent; 70 to 75 percent hazy calcific stenosis in the
mid right coronary artery beyond the second vein.
2. Left ventricular systolic function is severely decreased with severe
anterolateral wall hypokinesis with left ventricular ejection
fraction approximately 25 to 30 percent.
3. Patent left internal mammary artery with left subclavian artery,
patent right internal mammary artery with a patent right
brachiocephalic artery without any significant disease.
RECOMMENDATIONS:
1. The patient has developed new onset severe in-stent restenosis of
the proximal LAD stent and likely also mid LAD stent. He is a
diabetic. The stent was implanted in the LAD on 08/08/2017, thus
this is a hyper-response to in-stent stenosis within the stent and
hence recommend coronary artery bypass graft surgery to the mid to
distal LAD and the diagonal branch, to the second and first obtuse
marginal branches of the left circumflex artery, and the distal
right coronary artery.
2. The patient may likely have suffered stunning in the area of the
anterior wall of the left ventricle and hence expected to improve
the left ventricular systolic function.
3. Consultation with a cardiothoracic surgeon done, so that patient can
benefit from revascularization using LIMA graft, possibly RIMA
graft.
4. Maximal medical management of coronary artery disease and ischemic
heart disease to continue as before.
Stuck again.
I was going to code just 93459,26 and sedation but what about the Sel. Rt Brachiocephalic angiography???? Is this included in the 93459, 26 or can this be coded? 93455,26?
PROCEDURES PERFORMED:
1. Left heart cardiac catheterization.
2. Selective coronary artery angiography.
3. Left ventriculography.
4. Selective left internal mammary artery angiography and left
subclavian vein artery angiography.
5. Selective right brachiocephalic artery angiography and right
internal mammary artery angiography.
6. Intravenous conscious sedation using 1 mg of Versed and 3 mg of
morphine for a total of conscious sedation time of about 36 minutes.
INDICATIONS:
1. Coronary artery disease with history of angioplasty and stent to the
ostial proximal LAD and mid LAD in August 2017 with a previous
history of stent in the right coronary artery and significant
high-grade lesion in the first obtuse marginal branch of the left
circumflex artery with 80 percent stenosis, 75 percent of the mid
right coronary artery.
2. Previous history of coronary artery angioplasty and stent, the last
stent on 08/08/2017 to the ostial proximal LAD 3.5/18 mm Xience
stent and in the a mid LAD with a 2.5/18 mm Xience stent.
3. Hypertension and hypertensive heart disease.
4. Diabetes mellitus.
5. Previous history of ischemic heart disease and recurrent angina
pectoris.
PROCEDURE IN DETAIL: After the informed consent was obtained, the patient
was prepped and draped in the usual sterile fashion. Two percent lidocaine
was used for local anesthesia in the right groin. Vascular access was
obtained in the right femoral artery and over a guide wire 6-French
angiographic sheath was placed in the right femoral artery.
Over a guidewire, 6-French XB 3.5 guide without side holes was used to
engage the left coronary artery. The left coronary angiography was
performed.
Then, a 6-French JR4 catheter was used to selectively engage the right
coronary artery and selective right coronary artery angiography was
performed.
A 6-French _____ catheter was used to selectively engage the left
subclavian artery. Selective left subclavian artery to visualize the left
internal mammary artery was performed. Left subclavian artery angiography
and left internal mammary artery angiographies were performed.
A 6-French JR4 catheter was used to selectively engage the right
brachiocephalic artery and right brachiocephalic artery angiography to
visualize the right internal mammary artery was performed.
Then, a 6-French pigtail catheter was introduced through the guidewire in
the left ventricle. Left ventricular hemodynamics were measured and left
ventriculography in the RAO projection was performed. The pigtail catheter
was removed under hemodynamic monitoring from the left ventricle to the
aorta.
At the end of the diagnostic cardiac catheterization, the guidewire and
diagnostic catheters were removed. Arterial sheath was sutured in place
and the patient was transferred in a stable condition to the floor for
further care with no complications. The pigtail catheter was removed under
hemodynamic monitoring from the left ventricle to the aorta.
COMPLICATIONS: None.
FINDINGS:
HEMODYNAMIC DATA:
1. Aortic pressure 123/74/96 mm mean.
2. Heart rate 74 beats per minute.
3. Left ventricular pressure of 122/3/18 mm.
ANATOMIC FINDINGS:
LEFT VENTRICULOGRAPHY:
1. Left ventricle appears to be mildly dilated.
2. Anterobasal, moderate-to-severe hypokinesis.
3. Anterolateral, severe hypokinesis.
4. Apical, severe hypokinesis.
5. Inferior normal.
6. Posterobasal normal.
7. Left ventricular ejection fraction is approximately 25 to 30 percent
by visual estimate with no significant gradient across the aortic
valve noted, 1 to 2 plus mitral insufficiency noted.
CORONARY DATA:
1. Heavy calcification noted in the mid LAD and mid left circumflex
artery and the mid right coronary artery.
2. LEFT MAIN CORONARY ARTERY: The left main coronary artery has no
high grade focal stenosis. It divides into left anterior descending
artery and left circumflex artery. It is a moderate caliber vessel.
It also gives rise to the small ramus intermedius artery. Left main
coronary artery is a moderate caliber vessel. It has no high grade
focal stenosis. It divides into left anterior descending artery,
left circumflex artery, and a small ramus intermedius artery.
3. LEFT ANTERIOR DESCENDING ARTERY: The left anterior descending
artery is totally occluded within the stent and in its proximal
portion. The entire LAD is not visualized with antegrade flow, but
the mid and distal LAD is noted to fill via retrograde collaterals
from right to left and it is a small caliber vessel. It seems to
have occlusion in the mid portion within the stent also.
Left anterior descending was previously known to have 2 diagonal
branches. The first diagonal branch is a small vessel. The second
diagonal branch is a small-caliber vessel with a high-grade 90
percent stenosis in the mid portion of the second diagonal branch.
The entire mid distal LAD was a small caliber vessel, was a
trans-apical vessel, as was visualized previously and also now seen
faintly via the collaterals.
4. LEFT CIRCUMFLEX ARTERY: The left circumflex artery is a
moderate-caliber vessel in the proximal portion, maximum 90 degree
bend in the early proximal portion with moderate disease and
possibly moderate stenosis of 60 percent with calcification. The
proximal left circumflex artery gives rise to a small obtuse
marginal branch, distally diseased. The left saphenous artery has
mild-moderate calcification with an eccentric 50-60 percent stenosis
distal to this. The left circumflex artery gives rise to a small AV
circumflex artery. The distal left circumflex artery bifurcates in
to 2 obtuse marginal branches and into the second and third obtuse
marginal branches.
The second obtuse marginal branch is a 2.25 mm caliber vessel with
the proximal 80 percent stenosis followed by another 80 percent
stenosis in the distal portion.
The third obtuse marginal branch is a medium-caliber vessel,
tortuous in its course with mild disease.
5. RIGHT CORONARY ARTERY: Right coronary artery is a large dominant
vessel. Proximal right coronary artery has a calcific 50 percent
stenosis at the first vein.
Mid right coronary artery is a patent stent with a 20 to 30 percent
focal in-stent stenosis and mild 20 percent diffuse in-stent
stenosis.
At the distal edge of the stent, the right coronary artery has a
focal 40 percent stenosis.
Just after the second main, the right coronary artery has a hazy
diffuse calcific 70-75 percent stenosis.
Distal to this, the right coronary artery bifurcates into the
posterior descending branch and a posterolateral branch.
The posterior descending branch is a medium-caliber vessel with mild
disease.
The posterolateral branch gives rise to 4 other small posterolateral
branches and is a medium-caliber vessel with mild disease.
6. LEFT SUBCLAVIAN ARTERY: The left subclavian artery has no
significant disease. It gives rise to the left internal mammary
artery. The left internal mammary artery is a medium-caliber vessel
without significant disease.
7. RIGHT BRACHIOCEPHALIC ARTERY: Right brachiocephalic artery has no
significant disease. It gives rise to right internal mammary artery.
The right internal mammary artery has no significant disease.
IMPRESSION:
1. Severe 3-vessel coronary artery disease with a total occlusion of
the proximal left anterior descending with in-stent restenosis as
well as likely mid left anterior descending stent as noted by
collaterals from right to left; eccentric 60 percent calcific
stenosis of the early mid left circumflex artery; second obtuse
marginal branch with 2 sequential lesions of 80 and 80 percent
stenosis in the mid and distal portion; right coronary artery with a
50 percent proximal stenosis, patent stent in the midportion, focal
30 percent in-stent restenosis; 40 percent stenosis of the distal
edge of the stent; 70 to 75 percent hazy calcific stenosis in the
mid right coronary artery beyond the second vein.
2. Left ventricular systolic function is severely decreased with severe
anterolateral wall hypokinesis with left ventricular ejection
fraction approximately 25 to 30 percent.
3. Patent left internal mammary artery with left subclavian artery,
patent right internal mammary artery with a patent right
brachiocephalic artery without any significant disease.
RECOMMENDATIONS:
1. The patient has developed new onset severe in-stent restenosis of
the proximal LAD stent and likely also mid LAD stent. He is a
diabetic. The stent was implanted in the LAD on 08/08/2017, thus
this is a hyper-response to in-stent stenosis within the stent and
hence recommend coronary artery bypass graft surgery to the mid to
distal LAD and the diagonal branch, to the second and first obtuse
marginal branches of the left circumflex artery, and the distal
right coronary artery.
2. The patient may likely have suffered stunning in the area of the
anterior wall of the left ventricle and hence expected to improve
the left ventricular systolic function.
3. Consultation with a cardiothoracic surgeon done, so that patient can
benefit from revascularization using LIMA graft, possibly RIMA
graft.
4. Maximal medical management of coronary artery disease and ischemic
heart disease to continue as before.