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These are the codes we want to use for this inpatient Medicare pt.
35371-RT
37221-RT
36140-XS-RT
75625
Many thanks. Kristi
Pre-op Diagnosis:
1. Atherosclerotic PVD with intermittent claudication RLE [I70.219]
2. CKD
3. HTN
Post-op Diagnosis: same
Procedure(s):
1. Right common femoral endarterectomy with bovine pericardial patch
angioplasty
2. Aortogram via L CFA approach
3. Selective catheterization of R EIA
4. R EIA PTA, stent placement, 8 x 60mm
Anesthesia: General
Estimated Blood Loss: 200 mL
CONTRAST: 50 cc
Drain: none
Total IV Fluids: see anesthesia log
Specimens:
ID Type Source Tests Collected by Time Destination
A : RIGHT FEMORAL PLAQUE Tissue Plaque SURGICAL PATHOLOGY
Implants:
Implant Name Type Inv. Item Serial No. Manufacturer Lot No. LRB No.
Used
PATCH VASCULAR VASCU-GUARD BOVINE PERICARDIUM L8 CM X W.8 CM PERIPHERAL
STERILE – SN/A Patch PATCH VASCULAR VASCU-GUARD BOVINE PERICARDIUM L8 CM X
W.8 CM PERIPHERAL STERILE N/A SYNOVIS MICRO COMPANIES ALLIANCE INC – A
BAXTER HEALTHCARE CORP CO SP18B02-1270178 Right 1
mynx N/A CARDINAL HEALTH INC F1805704 Left 1
Complications: none
Findings: R EIA occlusion with bulky calcified plaque extending into R
CFA. S/p endarterectomy. Unable to cross EIA lesion from retrograde
approach therefore L CFA access was obtained and lesion was crossed from
an antegrade approach. Self-expanding 8 x 60mm stent was placed was good
result. Palpable pedal pulses upon completion.
Disposition: awakened from anesthesia, extubated and taken to the recovery
room in a stable condition, having suffered no apparent untoward event.
Condition: doing well without problems
Technique:
After informed consent was obtained the patient was taken to the operating
room. Placed in the supine position. General endotracheal anesthesia was
administered. The abdomen and bilateral groins were prepped and draped
usual sterile fashion.
We began by making an incision in the inguinal
right area right groin midline between a cyst in the pubic tubercle in
vertical fashion. We dissected through the skin subcutaneous tissue
Scarpa’s fascia until we encountered the femoral sheath. Any veins that
were seen were tied off and suture ligated. Then got into the femoral
sheath identified our inguinal ligament and then our right common femoral
artery. It was noted to be calcified with some posterior plaque and some
inflammation noted. We dissected systemic fashion inferiorly identifying a
few branches and putting small Vesseloops around. We then identified the
SFA and profunda. Placed vessel loops around them. We then continued our
dissection more proximally we had to divide part of the inguinal ligament
to get more proximal control.
At this point, we began our endarterectomy
we heparinized the patient and obtained ACTs every 30 min to remain
therapeutic. Once the patient was therapeutic we got control with vessel
loops and then performed an arteriotomy with an 11 blade and extended it
with Potts scissors. The common femoral artery had noted hemorrhagic
calcified plaque. We then perform an endarterectomy between the median
intima with a Freer elevator and piecemeal off the plaque in the common
femoral artery. We then made our endpoint at the distal common femoral
artery. There was noted to be calcified posterior plaque on the proximal
aspect of our endarterectomy site with a chronic occlusion.
We attempted
to access through the open endarterectomy vessel the right external iliac
artery with a Glidewire 035 as well as a 5 French sheath. When we
advanced the wire and there was mild resistance proximally we advance into
what we thought was the abdominal aorta we then performed an angiogram
which demonstrated a dissection plane at this point we then stopped access
from this area. We removed the sheath and the wire and then gain access on
the opposite groin. At this point we then gain access to the left groin
under palpation using Seldinger technique.
We accessed the left common
femoral artery and then we upgraded to a 5 French sheath. We then
advanced a Glidewire and a VCF catheter and performed a angiogram with
minimal contrast. This demonstrated extensive infrarenal calcification in
bilateral patent common iliac arteries. The left hypogastric appeared to
be occluded. The left external iliac had multilevel disease but nothing
hemodynamically significant. The right common iliac artery appeared to be
patent the external had a flush occlusion about 1 cm after the takeoff.
The left hypogastric artery appeared to be patent with an ostial lesion.
There was extensive pelvic collaterals and reconstitution at the femoral
head of the common femoral artery. At this point we then upgraded to a 6
French up-Andover sheath and advanced it over the bifurcation into the
right common iliac artery. We then used a support Seeker catheter within
and a stiff 035 glidewire and was able to go through the chronic occlusion
of the left external iliac artery into our endarterectomy site in the
right common femoral artery. We then switched snared the Glidewire
through the right common femoral artery endarterectomy site. At this point
we then placed a 6 French sheath through the Glidewire in the right groin
and then we used a 8 x 60 mustang balloon used to measure the length of
our occlusion. At this point we then decided to use a 8 x 60 self
expanding stent. We deployed the stent in standard fashion at the takeoff
of the hypogastric artery with the endpoint proximal to the femoral head.
We then post dilated with a 8 x 60 mustang balloon. Postop angiogram
demonstrated good apposition of the stent with no hemodynamic significant
stenosis noted. We then at that point, performed a patch angioplasty with
a pericardial patch with 6 0 Prolene in standard fashion. Before
completing the patch angioplasty we forward flushed and backflushed the
common femoral artery. Before completing the full angioplasty, we left
the wire in place and then performed a angiogram which demonstrated
patency of the right common iliac artery as well as external iliac artery
and common femoral artery with no hemodynamic significant stenosis. The
right groin shot demonstrated patency of the profundus as well as the SFA.
At that point we then finished our patch angioplasty and endarterectomy
site. Everything was noted to be hemostatic and mildly oozy. We reversed
the patient with protamine. We dried out any bleeding points with Bovie
electrocautery and clips. We then closed the right groin in layers of
Vicryl multiple. We closed that the subdermal with 3 0 Vicryl pop offs
and the skin with 4 O Monocryl subcuticular stitches. Sterile dressing was
then applied.
On the left groin we downsized to a 6 French sheath over the
wire under fluoroscopic guidance. We then used a 6 French Mynx closure
device and closed the left common femoral artery at the access site. In
standard fashion. Sterile dressing was then applied. At completion of the
procedure the patient had a palpable right pedal pulses. Patient tolerated
the procedure well was extubated transferred to the PACU in stable
condition.
I was wondering if i could get some advice on learning how to code Cardiac Caths. Cardiology is my weakest specialty and i need help learning how to better code Caths. Can some one help point me in the right direction.
Thank you,
Robin
Ultrasound guidance sheath was used to access the radial artery when doing a Heart Catheterization. Is this billable when doing a Heart Catherization ? If so what is the CPT Code?
Thanks,
Kayla
PROCEDURE PERFORMED:
1. Left heart catheterization.
2. Coronary angiography.
3. Percutaneous transluminal coronary angioplasty of the right coronary
artery.
4. Left ventriculogram.
5. Temporary balloon pacing catheter placement.
6. Placement of an intraaortic balloon pump.
INDICATIONS FOR PROCEDURE: This is a 79-year-old lady, who presents
approximately 90 minutes into an inferior myocardial infarction. She has
no previous cardiac history. She had a history of some hypertension only.
DESCRIPTION OF PROCEDURE: Informed consent had been obtained and the
patient was brought emergently to the cardiac catheterization lab for ST
elevation myocardial infarction. She was sterilely prepped and draped in
usual fashion. The right femoral artery entered using the modified
Seldinger technique and a 6-French arterial sheath easily established.
Following this, left heart catheterization done. A 6-French JL4 and JR4
catheters were used to perform multiple coronary angiograms in multiple
projections. The right coronary was anomalous and had a high anterior
takeoff. Subsequent to this, we attempted to do angioplasty. The right
coronary proved extraordinarily difficult to engage, unsuccessful cath
included a JR4, AL1, AR1. We did successfully get in with an LCD. Its
support was not overly great. We also subsequently tried a 3.0 and a
hockey stick guide, which were also not effective. In fact, the only
guide that even allowed the passage of a wire was the LCD. The patient
received Angiomax bolus infusion. She had received aspirin in the ER, but
did not receive any other antiplatelet therapy in the lab.
Once we were able to get the LCD guide at least adequately seated, we did
cross the lesion with mild difficulty with a graphics wire. We then
attempted the pass a 2.5 x 15 Trek balloon, but found it would not
negotiate the extremely surfing time like origin of this vessel, which
also appeared to have a significant stenosis in it. With the placement of
a second wire, which was a Whisper ES we were able to get the balloon down
to the distal lesion where it was deployed to 10 atmospheres times about
20 seconds. This did restore some better flow. We also did use this
balloon in the proximal. I attempted to go back and do for the proximal
vessel, but it would not cross. We did get a 2.5 x 15 NC Trek across the
area in the proximal vessel and deployed that at about 10 atmospheres
times 20 seconds. There was no evidence of any sort of waste. At this
point, we did attempt to stent a 2.75 x 15 Xience, did not even remotely
come close to getting into the vessel. There is absolutely no way to
negotiate that proximal area. We did lose our entire system trying to do
this. We went in again to reengage and recross the wire, then we were
able to get a wire again and then this time a 3.0 x 15 Trek balloon down
to the distal vessel. The vessel initially had looked bad after the first
2.5 balloon, but in the interim developed less good flow again and in fact
it was more sluggish and actually she developed some transient heart
block. This did require the placement of the 5-French pacing catheter.
The access had been obtained in the right femoral vein via modified
Seldinger technique and a 5-French sheath was established and the balloon
catheter positioned in place. Adequate pacing parameters were confirmed.
We then again went back to work with the balloon angioplasty. This was
the 3.0 balloon. It was taken out up for about 20 seconds at about 10
atmospheres. The lesion looked quite a bit better. It was better flow
and less area of visible thrombus in that area. We attempted to also do
the ostium with this balloon, but found that it was initially we were not
able to get back far enough to be on the lesion and out of the guide. I
then withdrew the guide and the entire system again was lost. Basically,
the anatomy of this patient’s proximal right coronary being one anomalous,
two extremely serving time in its course and three having significant
plaque present, made passage of a winged balloon or stents absolutely
impossible.
At this point, it became evident that we were not going to be successful
with stenting this lesion. I was concerned that it would not have
durability in terms of staying open. Therefore, at this point, we did opt
to pursue an emergent surgical consult. Dr. Blitz was consulted and he
came by and reviewed the films and agreed to take the patient for emergent
bypass. The anticipated graft will be to the right coronary and to the
LAD. At this point, he did request a balloon pump be in place, which is
certainly reasonable. Therefore, we did go ahead and exchange our sheath
and put in a balloon pump, it was placed on one-to-one support.
As the patient was just living the cath lab, she has her ST segments
considerably better. There is slight residual ST elevation, but it does
look a lot better and also her chest pain is significantly improved. This
patient has been very noncooperative as well, making his case even much
more difficult. She has a lot of chronic back problems and was constantly
moving around her legs and arms and body the entire case. Therefore, we
needed to monitor very carefully with the balloon pump in place.
At this point, the balloon pump was left and of course and also the pacing
catheter, though her transient heart block seems to have resolved at least
at the end of the case that she is no longer requiring the pacemaker, but
nonetheless _____, heart block returned.
The intra-procedure medicines include Angiomax bolus infusion and
sedatives and pain medications per the nursing flow sheets, quite a bit
was used and I did detailed in those notes. No other antiplatelet agents
were added. The contrast and flow amounts were elucidated in the cath lab
report.
STUDY FINDINGS:
HEMODYNAMICS: Central aortic pressure was about 131/66. The LV pressure
measured about 140/17, but did not suspect that there is significant
gradient.
ANGIOGRAPHIC FINDINGS: The left main is a moderate-sized vessel, free of
any significant disease.
Left circumflex is a moderate-sized system, does not appear to be
significant disease. It gives rise to a single tortuous obtuse marginal
branch, which has about a 20 percent proximal lesion.
The LAD has a tubular 80 percent proximal stenosis. This vessel is large
and very tortuous, does reach around the apex.
There is a moderate-sized diagonal branch, free of significant disease.
The right coronary artery is large and dominant vessel with an anomalous
takeoff, it comes off anteriorly. There is likely an 80 to 90 percent
ostial stenosis. The area was 100 percent occluded in the distal vessel
that was opened up and then the final angiogram as a residual stenosis in
the distal vessel of about 50 percent with some thrombus present. Initial
TIMI 0 flow is restored to TIMI 3 flow. The area in the ostium of the
right coronary, where the 89 percent stenosis present is not significantly
changed.
Left ventriculogram was attempted via hand injection; however, contrast
opacification is poor. The patient’s hand came in front and basically it
was not really interpretable.
OVERALL IMPRESSION:
1. Severe 2-vessel disease involving the distal right coronary for her
culprit for the acute inferior myocardial infarction and also
significant high-grade disease in the proximal LAD.
2. Difficult to assess left ventricular systolic function.
3. Successful placement of both the intraaortic balloon pump and
temporary transvenous pacing catheter.
RECOMMENDATIONS: The patient will be supported on her balloon pump. I
should also mention that we did transiently use some dopamine during the
case, she became hypotensive when she had her heart block and her
bradyarrhythmia that was discontinued by the end of the case. At the time
of her leaving the cath lab is on standby. We will continue to support
her temporarily until she goes to the operating room for emergent bypass.
PROCEDURE PERFORMED:
1. Left heart catheterization.
2. Coronary angiography.
3. Left ventriculogram.
INDICATIONS FOR PROCEDURE: A 59-year-old patient with longstanding
coronary artery disease. He now presents with increasing dyspnea symptoms
which has been angina equivalent in the past. Given this finding along
with the fact that this patient does have profession of a bus driver, we
felt it best to proceed with an invasive risk stratification with at least
an intermediate _____ clinical suspicion for disease progression.
DESCRIPTION OF PROCEDURE: Informed consent was obtained. The patient was
brought to the cath lab in a fasting condition. He was sterilely prepped
and draped in usual fashion and the right femoral artery entered using a
modified Seldinger technique. A 6-French arterial sheath was easily
established. Following this, left heart catheterization was done with a
6-French JL4 and JR4 catheter being used to perform multiple coronary
angiograms in multiple projections. Afterwards, a 6-French pigtail was
inserted across the aortic valve and into the left ventricle. Hemodynamic
data was gathered. Left ventriculogram was done in the RAO projection.
The catheter was pulled back across the aortic valve, no gradient was
seen. At this point, review of the angiograms finds no obstructive
disease and no significant progression over the prior evaluation.
Therefore, all catheters, wires were removed. The arterial sheath was
removed and hemostasis obtained with manual compression. There were no
immediate complications.
STUDY FINDINGS:
HEMODYNAMICS:
Central aortic pressure was 137/73. Corresponding _____, no gradient
across the aortic valve.
ANGIOGRAPHIC FINDINGS:
Left main: The left main is a moderate size vessel, free of any
significant disease. The LAD has been previously stented in the proximal
and mid vessel. There are some older, Wiktor stents which appear patent.
There is also newer stent which has been placed in the distal portion of the second stent, which remains widely patent with no in-stent restenosis.
The Wiktor stent do not appear to have any high grade in-stent restenosis
either, the more proximal of the two may have some diffuse and perhaps 25
percent narrowing. The more distal LAD is free of any significant
disease.
Left circumflex: The left circumflex is a small system with just mild
irregularities proximally, it gives rise to very tiny obtuse marginal
branch, there is a large ramus intermediate vessel present which is a
bifurcating vessel. This has some diffuse disease at about 25 percent of
the mid portion, but no high-grade lesions are seen. The right coronary
artery is a dominant vessel. It also has a Wiktor stent in the mid
portion, which is widely patent. The ongoing vessel has some mild
plaquing not exceeding 20 percent towards the distal portion, but no high
grade lesions. The posterior descending is a small caliber with long in
length vessel without significant disease. The posterior lateral branch
similarly is long in caliber without significant disease.
Left ventriculogram in the RAO projection demonstrates some mild
hypokinesis to the inferior basal and mid and now toward the inferior
apex. Overall, ejection fraction is estimated to approximately 45-50
percent.
OVERALL IMPRESSION:
1. Nonobstructive coronary artery disease. Previously placed stents
remain widely patent.
2. Mildly reduced left ventricular systolic function, ejection fraction
of approximately 45-50 percent, probably closer to 50 percent.
0480 Cardiology general classification
0481 Cardiology cardiac cath lab
Thanks!
I have a scenario where the patient was seen for 90 mint in Critical Care -99291, 99292. There was also 93458 done on the same day. Can I bill the Critical Care on the same day as the heart cath ?