Wiki Right Atrial Thrombectomy

[ellis3350]

I have a case where the patient has an infective endocarditis and is having a mechanical aspiration thrombectomy of a right atrial mass, and they are using cerebral embolic protection. I'm looking at using unlisted 93799 and comparing it to 92973 but just not sure. Any help would be appreciated. Thanks.

 

[ashae17]

I see the dilemma here, but it would help to be able to look at the documentation to get the full picture, since I have questions that can't be answered with the description of the procedure you provided. Let me know if you can add the documentation.

 

[ellis3350]

I see the dilemma here, but it would help to be able to look at the documentation to get the full picture, since I have questions that can't be answered with the description of the procedure you provided. Let me know if you can add the documentation.

PROCEDURE(S) PERFORMED
Cerebral Embolic Protection
Ultrasound- guided vascular access
Intervention: Mechanical thrombectomy of Right Atrial Mass
Ultrasound- TTE (Transthoracic Echocardiogram)


Clinical History:
Current/Recent Smoker (within 1year): Yes Cigarettes Light use (<10/day)
Other: Admitted with sepsis secondary to endocarditis
Other: Presents for thrombectomy of right atrial thrombus

Pre-OP Diagnosis/Indication:
Intracardiac shunting
Infected mass right atrium



ASA status unchanged immediately prior to sedation administration. Heart,
lungs, and airway assessed prior to sedation.

The risks, benefits, and side effects related to alternative treatment
options and the risks related to not receiving the proposed interventions
and care were discussed with the patient. Following informed consent, the
patient was brought to the procedure room in the fasting state. right wrist
& bilateral groins was prepped and draped in a sterile fashion. Local
anesthesia was attained with 2% lidocaine to the right radial region. Using
standard technique, sheath(s) were placed in the following site(s):

right radial artery - 5-6F 10cm Glidesheath Slender
exchanged into the right femoral vein - 8F 10cm Pinnacle Sheath
exchanged into the right femoral vein - 24F 33cm Gore Dry Seal Sheath
after 16 and 20 f dilators
inserted into the right common femoral vein - 4F 10cm Mini Stick Max micro
introducer catheter
exchanged into the right femoral vein - 8F 10cm Pinnacle Sheath
exchanged into the right femoral vein - 24F 33cm Gore Dry Seal Sheath
after 16 and 20 f dilators

Catheters were advanced using standard guide wire technique. Multiple
angiographic pictures were taken and appropriate pressures obtained.

Hemodynamics:

After review of the angiography and assurance of the patient's stability,
the catheter was withdrawn from the sheath and pulled . Previously placed
perclose to the right common femoral vein completed by Dr X , manual
pressure held for 5 mins
Radial sheath pulled. Radial band used, inflated with 10 mls of air

FINDINGS:

Other findings:
Insertion of Sentinel embolic protection device

Mechanical thrombectomy of Right Atrial Mass


PERIPHERAL INTERVENTION
Mechanical thrombectomy of right atrial mass. Successful removal of mass
without residual. Confirmed by TTE.

POST-OP DIAGNOSIS:
Infected right atrial mass - s/p successful intervention.

 

[ashae17]

I'm a little bit confused, since there is mention of the angiography however the actual findings of everything viewed and pressures (stenosis, patency, etc) is not provided. Since this is a right atrial mass..right atrium would be right side of the heart, it would make more since that they performed coronary angiography and heart catheterization (right side, original access gained through right femoral vein), if so then you would then be able to report from code range 93454-93461 (likely 93456), which CPT 92973 can be reported with. CPT 92973 can't be reported by itself. (Also, there is no mention of aspiration thrombectomy in the documentation, only mechanical). Going based off of what's documented, you'd report right femoral angiography, that would be CPT 75710 which isn't supported as primary code for CPT 92973, in that case you would have to report that as the unlisted code. If you're able to clarify with the physician (preferably an amendment added), that would be good. This report is lacking a lot of description when it comes to the angiography, and even the mechanical thrombectomy, it's basically only stated that it was performed, however the procedure itself is not described much, if at all.

 

[ellis3350]

I'm a little bit confused, since there is mention of the angiography however the actual findings of everything viewed and pressures (stenosis, patency, etc) is not provided. Since this is a right atrial mass..right atrium would be right side of the heart, it would make more since that they performed coronary angiography and heart catheterization (right side, original access gained through right femoral vein), if so then you would then be able to report from code range 93454-93461 (likely 93456), which CPT 92973 can be reported with. CPT 92973 can't be reported by itself. (Also, there is no mention of aspiration thrombectomy in the documentation, only mechanical). Going based off of what's documented, you'd report right femoral angiography, that would be CPT 75710 which isn't supported as primary code for CPT 92973, in that case you would have to report that as the unlisted code. If you're able to clarify with the physician (preferably an amendment added), that would be good. This report is lacking a lot of description when it comes to the angiography, and even the mechanical thrombectomy, it's basically only stated that it was performed, however the procedure itself is not described much, if at all.

I totally agree that the documentation is lacking. We do have a nursing procedure log that we also use but not able to share much of it here accept this info below. I appreciate any help. Thanks.

Surface ultrasound used for vascular access. Imaging obtained and stored in current
cardiovascular PACS.
4/26/2021 17:19:36 Percutaneous stick to the right radial artery per - Dr.
4/26/2021 17:20:44 Access: Sheath was inserted into the right radial artery - 5-6F 10cm Glidesheath Slender
4/26/2021 17:21:56 Sentinel cerebral protection system inserted over the wire.
4/26/2021 17:21:56 Sentinel distal embolic filter delivered to the left common carotid artery.
4/26/2021 17:21:56 Sentinel proximal embolic filter delivered to the brachiocephalic artery.
4/26/2021 17:22:00 HR: 80, DURING, NIBP: 101 / 64, LOC: 0 , LOP: 0 , RESP: 23, SPO2: 99, NOTES: Sinus Rhythm
4/26/2021 17:26:54 HR: 83, DURING, NIBP: 104 / 61, LOC: 0 , LOP: 0 , RESP: 22, SPO2: 97, NOTES: Sinus Rhythm
4/26/2021 17:28:14 Local anesthetic to right groin region with 2% lidocaine SQ, total injected 5 mls
4/26/2021 17:29:39 Venous access: Sheath was inserted into the right common femoral vein - 4F 10cm Mini Stick
Max micro introducer catheter
4/26/2021 17:29:53 Venous access: Sheath was exchanged into the right femoral vein - 8F 10cm Pinnacle Sheath
4/26/2021 17:30:00 Venous access: Perclose preclosure of the right common femoral vein performed by dr and dr
4/26/2021 17:30:27 Venous access: Sheath was exchanged into the right femoral vein - 24F 33cm Gore Dry Seal
Sheath after 16 and 20 f dilators

4/26/2021 17:31:27 Guide wire advanced -
4/26/2021 17:31:48 HR: 81, DURING, NIBP: 103 / 64, LOC: 0 , LOP: 0 , RESP: 16, SPO2: 97, NOTES: Sinus Rhythm
4/26/2021 17:32:54 {Procedure} Ultrasound- TTE (Transthoracic Echocardiogram)

4/26/2021 17:33:02 Support catheter introduced over the wire - - .035 / 135cm Angled Navicross Support Catheter

4/26/2021 17:34:00 Guide wire advanced - - Amplatz super stiff wire 0.035 x 260cm 1 cm tip
4/26/2021 17:34:39 Thrombectomy catheter introduced over the wire. - INARI MEDICAL 24F 90CM FLOWTRIEVER
ASPIRATION GUIDE CATH
4/26/2021 17:34:49 {GUIDING CATH INARI} INARI MEDICAL 24F 90CM FLOWTRIEVER ASPIRATION GUIDE
CATH - Qty: 1 Each Part #: 11820265 Lot #: 21010010
4/26/2021 17:36:43 HR: 84, DURING, NIBP: 103 / 65, LOC: 0 , LOP: 0 , RESP: 9, SPO2: 99, NOTES: Sinus Rhythm
4/26/2021 17:40:15 TTE -imaging in progress By Dr .
4/26/2021 17:41:37 HR: 85, DURING, NIBP: 98 / 61, LOC: 0 , LOP: 0 , RESP: 15, SPO2: 97, NOTES: Sinus Rhythm
4/26/2021 17:43:36 Thrombectomy catheter aspiration volume= 60 mls
specimen collected and sent with pathology orders
4/26/2021 17:46:31 HR: 84, DURING, NIBP: 99 / 64, LOC: 0 , LOP: 0 , RESP: 15, SPO2: 98, NOTES: Sinus Rhythm
4/26/2021 17:50:35 Catheter removed.
4/26/2021 17:50:46 device removed.
4/26/2021 17:51:02 Sentinel proximal embolic filter recaptured into the delivery catheter .
4/26/2021 17:51:02 Sentinel distal embolic filter recaptured into the delivery catheter.
4/26/2021 17:51:02 Sentinel cerebral protection system removed.
4/26/2021 17:51:25 HR: 74, DURING, NIBP: 102 / 61, LOC: 0 , LOP: 0 , RESP: 10, SPO2: 99, NOTES: Sinus Rhythm
4/26/2021 17:53:32 Sheath(s)- pulled . Previously placed perclose to the right common femoral vein completed by Dr
, manual pressure held for 5 mins
4/26/2021 17:53:49 Closure Method: #1: successful Device ID: 9-Perclose ProGlide
4/26/2021 17:53:53 Sheath(s)- Radial sheath pulled. Radial band used, inflated with 10 mls of air
4/26/2021 17:53:57 Closure Method: #2: successful Device ID: 2-Mechanical Compression
4/26/2021 17:53:58 Drape removed, procedure completed

 

[Jim Pawloski]

Well, you can't use 92973 as that is for removal of thrombus in the coronary arteries using Angiojet. Suction thrombectomy was performed. Really nothing on the arterial side, the carotid filter system can't be billed (don't know why it was used, since any clot from the RA goes to the lungs). I think your coding 33999. Can't bill RHC because of not pressure documentation.
HTH,
Jim Pawloski, CIRCC

 

[ellis3350]

Well, you can't use 92973 as that is for removal of thrombus in the coronary arteries using Angiojet. Suction thrombectomy was performed. Really nothing on the arterial side, the carotid filter system can't be billed (don't know why it was used, since any clot from the RA goes to the lungs). I think your coding 33999. Can't bill RHC because of not pressure documentation.
HTH,
Jim Pawloski, CIRCC

Thanks for your help. I appreciate it.