Laureen shows you her proprietary “Bubbling and Highlighting Technique”
Download your Free copy of my "Medical Coding From Home Ebook" at the top right corner of this page
Any advice or suggestions?
Thank you,
Sabrina Fox, CPC, CCA
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.
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 ?
I have a few cardiologists that want to bill 76937 when they access the radial artery and wanted to know if this is acceptable. I thought I had read somewhere that 76937 was for venous access procedures not arterial. Long story short, the doctors are performing mostly left and right heart catheterizations.
Thank you in advanced!
I am thinking that the LHC with angiography would be 93458, but I am not sure what code to use for the subclavian angiography.
Thank you in advance,
Pamela
If a patient had a diagnostic coronary angiogram 93456 and the very next day had an IABP placed 33967 and the provider is billing for another cardiac cath 93454 this time (this is all in preparation of a CABG to be done).
I feel the second day we can’t bill 93454 as the cardiac cath is not diagnostic, statement of left coronary circulation no changes post IABP (but did have full findings documented of all left coronary arteries).
Any advice would be greatly appreciated, thank you!
Thank you!!
Coding Clinic gives direction on heart failure, obstetrics, and linking language
by Laurie L. Prescott, MSN, RN, CCDS, CDIP
We are more than six months into the transition to ICD-10-CM/PCS, and at times it appears there are more questions than answers.
The last few weeks have brought us some direction, though, including the release of approximately 1,900 new ICD-10-CM codes for 2017. (The list can be found on CMS’ website.) We also have a list of approximately 3,600 new ICD-10-PCS codes for 2017. (This is also available on CMS’ site.) Of course, we will also be looking for changes in DRG mappings and the CC/MCC lists, which will likely appear later this summer.
The transition to ICD-10 was not a one-time process that ended on October 1, 2015?it will continue for quite some time. As CDI specialists, we must keep informed of the new information, including the latest guidance offered by AHA Coding Clinic for ICD-10-CM/PCS®.
The latest release, First Quarter 2016, focused on ICD- 10-CM diagnosis codes, in comparison to 2015, which focused more on the procedure side. One thing remains constant, though: It seems like every Coding Clinic offers some guidance that makes me think, "Finally, it’s about time!" yet also contains other pieces of advice that simply prompt more questions.
Heart failure differentiation
Let’s start with the long-awaited direction related to differentiation of heart failure. Coding Clinic heeded the American College of Cardiology and will now allow the more current descriptions of heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) to be coded as systolic and diastolic heart failure, respectively. This guidance is highly welcomed.
Obstetrics admission
For those who review obstetrical cases, there is guidance related to selection of principal diagnoses related to an obstetrics admission. The condition prompting the admission should be sequenced as the principal diagnosis for an obstetrical patient. If there is a complication of the delivery, the appropriate code would be assigned as a secondary diagnosis. Coding Clinic provides the example of an admission for premature rupture of membranes with a laceration complicating a delivery. In such a scenario, the principal diagnosis is pregnancy complicated by premature rupture of the membranes, and a secondary diagnosis of laceration would be assigned.
There is also guidance related to ICD-10-PCS code assignment for the repair of obstetrical lacerations; it instructs us to code the body part as related to the degree of the laceration or the deepest level of the repair as described (perineum, perineal muscle, rectal mucosa, and anal sphincter, for example).
Linking language
ICD-10-CM provides many opportunities to assign combination codes, especially those related to diabetes and the many complications associated with this condition. CDI specialists at your facility no doubt have worked diligently with providers to document the relationship using "linking language."
The question posed in this latest Coding Clinic asks if the provider must document the relationship between the two diagnoses or whether the coder can assume the relationship and assign the appropriate combination code. The answer provided (on p. 11 of Coding Clinic) actually left me more perplexed. It states:
The classification assumes a cause-and-effect relationship between diabetes and certain diseases of the kidneys, nerves and circulatory system. Assumed cause and effect relationships in the classification are not necessarily the same in ICD-9-CM as ICD-10-CM.
Several examples provided seem to infer that the relationship between diabetes and conditions such as polyneuropathy and ESRD can be assumed, unless of course there is documentation that indicates another identified cause.
Coding Clinic also reinforced the existing understanding that there is no assumed relationship between osteomyelitis and diabetes, as previously stated in Coding Clinic, Fourth Quarter 2013, p. 114.
So, although the direction related to osteomyelitis reinforces previous instruction, the direction related to diabetes and other conditions of the kidneys and nervous/ circulatory systems is brand-new and not particularly clear. What conditions are assumed and what are not? Where is "linking" required in documentation? I hope to receive further guidance related to these examples.
Review the latest Coding Clinic guidance related to diabetes and its manifestations to make sure that your CDI specialist team interprets these pieces of advice consistently. When you discover one of these "shades of gray" areas within the guidance, submit your questions to the Coding Clinic editorial board for clarification (they can be submitted at www.ahacentraloffice.org). The only way to learn is to ask questions.
Editor’s note: Prescott is the CDI education director at HCPro in Middleton, Massachusetts, and a lead instructor for its CDI-related Boot Camps. Contact her at [email protected]. The article originally appeared in CDI Journal.