This patient with prior treatment for coronary artery disease status post PCI ostial RCA x2, hypertension, dyslipidemia, severe aortic stenosis status post TAVR using a Medtronic valve has been complaining of substernal chest discomfort. Patient underwent Lexiscan stress test revealing evidence of anterior wall ischemia. Left heart catheterization was recommended.
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After obtaining informed consent, the patient was prepped and draped in sterile fashion. A 6 French glide sheath was inserted in the right radial artery. Radial cocktail consisting of 2.5 mg of verapamil and 200 mcg of nitro was administered via right radial artery sheath to prevent radial artery spasm. A 6 French Tiger catheter and Judkins right coronary catheters was used for left and right coronary angiography. TR band was placed on the right radial artery access site for patent hemostasis.
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I attest that moderate conscious sedation was provided under my direct supervision with the sedation trained nurse using 1 mg of intravenous Versed and 50 mcg of fentanyl to sedate the patient. Start time 11:06 AM and end time was 12:17 PM. There were no complications. See nurse’s sedation sheet, for complete pre-and post service details.
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Hemodynamics:
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The left ventricular pressure was 30 mmHg. The aortic pressure was 132/61 mmHg.
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Coronary Angiography:
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Right coronary artery large caliber dominant vessel with patent ostial proximal stent with mild mid 20-30% stenosis, distal tubular 90 to 95% stenosis. It gives rise to small to medium caliber RPDA and RPL branches with mild luminal irregularities.
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Left Main coronary artery is patent.
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Left anterior descending is a large caliber vessel with mild proximal disease, mild 30% mid vessel stenosis, patent distal vessel. There is a 1 major diagonal branch is of medium caliber with mild luminal irregularities.
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Left circumflex is a large-caliber nondominant vessel with luminal irregularities. Obtuse marginal 1 is a small caliber vessel with luminal irregularities. Obtuse marginal 2 is a large caliber vessel with mild diffuse disease.
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Left ventriculogram: Left ventricular cavity was entered using 6 French guide catheter and LVEDP was measured at 30 mmHg.
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The patient was then transferred to the recovery area in stable condition:
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Summary conclusion:
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1. Severe 1 vessel CAD involving the distal RCA.
2. History of coronary disease status post PCI of ostial RCA x2
3. Severe aortic stenosis status post TAVR using a Medtronic valve
4. Hypertension
5. Dyslipidemia
6. Obesity plan
7. Atrial fibrillation
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Recommendation:
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Recommend PCI of distal RCA.
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6 French Williams right diagnostic catheter was used to engage RCA. She was anticoagulated using 80 units/kg heparin. 300 cm run-through wire was advanced into distal RCA. Catheter was exchanged for a 6 French JR4 guide with sideholes. Attempting delivering a 2.5 x 15 mm balloon which was unsuccessful. This was an extremely difficult cannulation of right coronary artery with history of ostial stents and Medtronic core valve implantation. Procedure was aborted at this time. Diagnostic angiography revealed TIMI-3 flow without any evidence of dissection or perforation. ACT measured during the procedure was 245. Patient received another 1000 units of heparin.
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Recommend plan PCI of distal RCA via right common femoral artery approach. We may use either hockey-stick versus AR mod guide.
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thanks in advance
should I only bill 93458 or failed intervention with 74 modifier?

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