Cardiomyopathy, ischemic [I25.5 (ICD-10-CM)]
Coronary artery disease involving native coronary artery of native heart with unstable angina pectoris (CMS-HCC) [I25.110 (ICD-10-CM)]
Abnormal cardiac function test [R94.30 (ICD-10-CM)]
Conclusion

This patient with a known history of ischemic heart disease distant history of inferior posterior lateral ST segment elevation myocardial infarction with RCA stenting and left ventricular systolic dysfunction subsequently had recently developed increasing dyspnea and deteriorating LV function, ejection fraction 30% or less and stress ischemic assessment revealed now in addition to inferior wall scar, apical ischemia LAD territory ischemia.
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Coronary angiography revealed patency of the stented RCA small circumflex and severe progressive disease in the proximal LAD. Given the patient’s severely reduced LV systolic function and proximal LAD intervention, high risk PCI is recommended but with support with Impella device.
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After obtaining informed consent from the patient, he was brought to the catheterization laboratory. A 6 French sheath was placed into the right common femoral artery under fluoroscopic guidance and a long sheath 6 x 25 was advanced into the lower abdominal aorta pre-bifurcation. Under direct roadmap visualization technique the left common femoral artery was entered and a 6 French sheath was placed. Patient was given 7000 units of heparin, ACT was documented to be greater than 250, and left arterial access was then dilated with 8 and then 10 French dilator and placement of an Impella 2.5 device sheath, 13 French. Over a standard guidewire a 5 French pigtail catheter was then advanced across the aortic bifurcation and positioned into the left ventricle. The guidewire was removed and a 0.018 long stiff support wire was then advanced into the left ventricle and the pigtail was removed and the Impella 2.5 device was then inserted across the aortic valve without difficulty and positioned. Impella flow was then initiated, after removal of the rapid exchange support wire.
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Utilizing the right common femoral access an EBU 3.75 guide was advanced to the left main coronary artery, left coronary angiography was performed, a wire was advanced into the distal LAD and angioplasty of the proximal LAD stenosis was performed with a 2.5 mm balloon followed by placement of a single Boston Scientific Promus drug-eluting stent 3.0 x 16 mm, and the entire stented segment was finally postdilated with a 3.5 mm balloon. After withdrawal of the balloon angiographic result was excellent, wire and guiding catheter was then removed. Iliofemoral angiography through the right common femoral sheath revealed the sheath in the right common femoral artery and closure on the right was then obtained with an Angio-Seal closure device.
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The patient’s Impella flow was then weaned, device was removed to the descending aorta flow dropped to P0 and the device was removed through the sheath. For hemostasis, this initial sheath was then exchanged out for a 14 French by 13 cm sheath which was then sutured into place with hemodynamic monitoring applied. Patient was transferred to the recovery area with palpable left DP pulse, and stable condition hemodynamically.
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Following resolution of elevated ACT, the left common femoral access sheath will be removed and manual compression utilized for hemostasis.
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Hemodynamics:
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Central aortic pressure 110/70 left ventricular pressure 110/16-18, no transaortic valvular gradient mildly elevated left ventricular end-diastolic pressure.
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Coronary angiography:
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Left main was patent left circumflex was small nondominant noncritical disease LAD was a large vessel which was quite dominant with proximal stenosis of 90%.
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PCI:
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Proximal LAD stenosis was treated with a single large drug-eluting stent dilated to 3.5 mm, excellent angiographic result.
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Summary and conclusion:
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Severe de novo proximal LAD stenosis, treated with successful supported PCI.
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Ischemic cardia myopathy ejection fraction 2530%, stable post PCI with Impella assist device.
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Recommendation:
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Left common femoral access sheath removal once ACT below 180-200 seconds, manual compression plan, continue dual antiplatelet therapy aspirin and Brilinta, patient to be admitted for hemodynamic monitoring and his severe ischemic cardiomyopathy post PCI of proximal LAD high risk PCI.
Radiation Tracking

Implants

SYSTEM CORONARY STENT 3MM 16MM PROMUS PREMIER MONORAIL EVEROLIMUS PLATINUM CHROMIUM RADIOPAQUE 1 ACCESS PORT BALLOON EXPAND INFLATE LUMEN 144CM ACCEPTS .014- IN GUIDEWIRE – SGTIN08714729844730 – LOG342634

Inventory item: SYSTEM CORONARY STENT 3MM 16MM PROMUS PREMIER MONORAIL EVEROLIMUS PLATINUM CHROMIUM RADIOPAQUE 1 ACCESS PORT BALLOON EXPAND INFLATE LUMEN 144CM ACCEPTS .014- IN GUIDEWIRE Serial no.: GTIN08714729844730 Model/Cat no.: H7493952816300
Implant name: SYSTEM CORONARY STENT 3MM 16MM PROMUS PREMIER MONORAIL EVEROLIMUS PLATINUM CHROMIUM RADIOPAQUE 1 ACCESS PORT BALLOON EXPAND INFLATE LUMEN 144CM ACCEPTS .014- IN GUIDEWIRE – SGTIN08714729844730 – LOG342634 Laterality: N/A Area: Coronary
Manufacturer: Boston Scientific Corp Action: Implanted Number used: 1
thank you in advance for your time and support
should I code 33990, c9600 his left heart cath was on a week prior and the patient was brought back for impella device implant and was removed same day I am hospital coder and this is our first impella case which is already denied per insurance so wanted to clarify the codes

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