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I have a report for PTCA that was done. The left anterior descending artery was difficulty to advance the wire into and there was significant angulation in the artery after multiple attempts the was lesion was dilated and a stent was placed. There was no time documented Is there anything you can bill for this being more difficult in the case?
Thanks,
Kayla
Procedure Log
Conclusion
XT 4-year-old male with history of coronary artery disease status post coronary artery bypass graft surgery and multiple interventions presenting with recurrence of severe chest discomfort and elevated troponin with non-ST elevation myocardial infarction was brought in for coronary angiogram. Procedure, risks, benefits, alternative options were explained. Risks including bleeding, infection, cerebrovascular accident, myocardial infarction, death, and arrhythmia were all explained patient was agreeable. He was brought into the cardiac cath lab where conscious sedation (moderate sedation) was performed by myself using Versed and fentanyl. Conscious sedation was started 10:40 AM and monitoring period Ended 11:38 AM. I was present throughout this whole entire period With the patient. Both groins were prepped and draped in the usual fashion. 2% lidocaine was used to anesthesize the skin. Using modified Seldinger technique, a 6 French sheath was inserted in the right femoral artery. Cardiac catheterization was performed using the usual catheters.
Finding:
1: Vein graft to the right coronary artery has a mid area of 50% in-stent restenosis that appears to be unchanged from recent angiogram
2: Vein graft to the left circumflex artery has an ostial haziness with 90% stenosis. The area of recent angioplasty appears to be widely patent in the middle of the vessel.
3: I did not inject the native coronaries as the patient had recent angiogram.
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Impression: There is stenosis in the origin of the vein graft to the left circumflex artery.
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Plan: Balloon angioplasty to the ostium of the vein graft to the left circumflex artery.
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Intervention:
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Using a L CB guiding catheter and a ATW marker wire I was able to cross to severe stenosis in the ostium of the vein graft to the left circumflex artery. The area was predilated with a 3.0 x 15 followed by 3.5 x 12 mm balloon. I also did balloon angioplasty in the mid vein graft at the area of recent angioplasty where there appears to be residual 30% stenosis. This responded very well with no residual stenosis. Repeat angiogram showed excellent result and no residual stenosis.
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Final impression:
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Severe stenosis in the origin of the vein graft to the left circumflex artery successfully treated with insertion of 3.5 mm balloon.
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thank you in advance
should I code 92920 or 92937-lc- since its graft ptca?
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This patient with prior treatment for coronary artery disease status post PCI to left circumflex, OM1, OM 2 in 2005, hypertension, dyslipidemia is having symptoms of exertional angina. He also had a abnormal stress test revealing inferolateral 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 nitroglycerin was administered via right radial artery sheath to prevent radial artery spasm. A 6 French Judkins left and right coronary catheters was used for left and right coronary angiography. TR band was placed on 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 11:57 AM and end time was 12:40 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 end-diastolic pressure was 19 mmHg. The aortic pressure was 114/61 mmHg.
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Coronary Angiography:
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Right coronary artery is a small nondominant artery with severe diffuse disease.
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Left Main coronary artery is patent.
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Left anterior descending is a medium to large caliber vessel with proximal 20-30% tubular disease at the bifurcation of diagonal 1, mild mid to distal luminal irregularities. Diagonal 1 and diagonal 2 are small caliber vessels with luminal irregularities.
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Left circumflex is a large caliber dominant vessel with patent proximal stent with mild to moderate ISR, moderate mid vessel disease and distal luminal irregularities. Obtuse marginal 1 has subtotal occlusion at the ostium with TIMI III flow in the mid to distal vessel. This was likely jailed during OM 2 stent deployment. Obtuse marginal 2 has severe 99% in-stent restenosis extending into the distal vessel. LPDA and LPL have mild luminal irregularities.
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Left ventriculogram: Left ventricular cavity was entered using guide catheter and LVEDP was measured at 19 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. Coronary disease status post PCI in 2005
2. Abnormal nuclear stress test
3. Angina
4. Hypertension
5. Dyslipidemia
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Recommendation:
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Recommend PCI of left circumflex/OM 2 due to evidence of inferolateral ischemia and a dominant circumflex territory.
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6 French XB 3.5 guide was used to engage left coronary system. Run-through wire was advanced into distal OM 2. A second run through wire was used as a buddy wire and advanced into distal left circumflex. Lesion was predilated using a 2.5 x 15 mm noncompliant balloon. Promus 2.5 x 32 mm stent deployed from left circumflex into OM 2 and postdilated up to 3.0 mm with stent balloon. Post stent deployment there was pinching of true circumflex. Run-through wire was withdrawn and readvanced through the stent struts and left circumflex was unrevealed using a 2.0 x 12 mm semi-compliant balloon. Postprocedure angiography revealed TIMI-3 flow without any evidence of dissection or perforation.
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Aspirin and Plavix for at least 12 months. Aggressive lipid control management.
Results
Contrast Administered (mL):
Implants
SYSTEM CORONARY STENT 2.5MM 32MM PROMUS PREMIER MONORAIL EVEROLIMUS PLATINUM CHROMIUM RADIOPAQUE 1 ACCESS PORT BALLOON EXPAND INFLATE LUMEN 144CM ACCEPTS .014- IN GUIDEWIRE – S08714729844952 – LOG337003
Inventory item: SYSTEM CORONARY STENT 2.5MM 32MM PROMUS PREMIER MONORAIL EVEROLIMUS PLATINUM CHROMIUM RADIOPAQUE 1 ACCESS PORT BALLOON EXPAND INFLATE LUMEN 144CM ACCEPTS .014- IN GUIDEWIRE Serial no.: 08714729844952 Model/Cat no.: H7493952832250
Implant name: SYSTEM CORONARY STENT 2.5MM 32MM PROMUS PREMIER MONORAIL EVEROLIMUS PLATINUM CHROMIUM RADIOPAQUE 1 ACCESS PORT BALLOON EXPAND INFLATE LUMEN 144CM ACCEPTS .014- IN GUIDEWIRE – S08714729844952 – LOG337003 Laterality: N/A Area: Coronary
Manufacturer: Boston Scientific Corp Action: Implanted Number used: 1
thank you in advance
my question is 93458-xu, c9600-lc should I also do 92920 lc? physician wants to add for his time
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I’ve never coded this before. Per the doctor he did: superior venal cavalgram, PTCA of SVC x 2, placement of wall stent in SVC.
Procedure as dictated:
Indication(s) for procedure:
The patient has known malignancy with superior vena caval symptoms, including flushing in her head, headache, and hypertension as well. She had a CT which showed a superior vena caval obstruction. She comes in today for assessment and relief of her severe superior vena caval obstruction due to cancer. She is also getting radiation at that site.
Description of procedure:
The patient was brought to the laboratory and put under the direction of anesthesia. Right jugular access was gained. A wire was placed. Angiography was performed and that confirmed the superior vena caval obstruction. Measurements were made and then we predilated the obstruction. First, with a Boston Scientific XXL vascular balloon, 14mm x 4cm, then repeated angiography, and then did another balloon dilation with an XXL 18mm x 4cm. This appeared to show significant improvement. I then placed a wall stent and a prosthesis, 22 x 35. I tried to pass the balloon to post dilate, but there was angulation and difficulty with the pass. I then did angiography and it showed the successful placement of the wall stent and really pretty good relief of the obstruction. We thought to be angiographically stable. The catheter was then pulled out of the jugular and direct pressure applied. The patient tolerated the procedure well.
Your thoughts are comments would be extremely helpful because I am lost!