dtruelson
Guest
When coding MI's -I've seen where it is said there should be no antegrade flow and others where flow is not mentioned, just that to be able to code 92941-- the patient has to be having the MI. What would you all code for the following?
All of your help is appreciated!!
Procedures
Angioplasty - Coronary
Stent DES - Coronary
Percutaneous Coronary Intervention
CORONARY ANGIO WITH POSSIBLE PTCA
Indications
NSTEMI (non-ST elevated myocardial infarction) [I21.4 (ICD-10-CM)]
Pre Procedure Diagnosis
NSTEMI
Case Tracking Events
Event Time In
Moderate Sedation Start 0915
Moderate Sedation End 1008
Conclusion
Two vessel coronary artery disease (LAD,RCA).
Successful percutaneous coronary intervention (drug eluting stenting) of the LAD and the diagonal branch of the LAD.
The patient was monitored continuously 1:1 throughout the entire procedure by me while sedation was administered.
Prep
Vital Signs AUC Assessment:
AUC score: 7
AUC indication: 16
HPI:Indication:
Revascularization by PCI or CABG of 1 or more arteries in a patient with NSTEMI or unstable angina with
Stabilization after presentation
High risk for clinical events
A (7) Indication: 16; Score 7
Vessel Findings
Diagnostic
Dominance: Right
Left Main
The vessel exhibits minimal luminal irregularities.
Left Anterior Descending
Ost LAD to Prox LAD lesion is 90% stenosed with 90% stenosed side branch in 1st Diag.
Left Circumflex
The vessel exhibits minimal luminal irregularities.
Right Coronary Artery
Ost RCA to Mid RCA lesion is 100% stenosed.
Right Posterior Descending Artery
Collaterals
RPDA filled by collaterals from Mid LAD.
Intervention
Ost LAD to Prox LAD lesion with side branch in 1st Diag
Stent - Main Branch
Drug-eluting stent was successfully placed. The stent used was a STENT RESOLUTE ONYX RX 3.00X26.
Stent - Main Branch
Drug-eluting stent was successfully placed. The stent used was a STENT RESOLUTE ONYX RX 3.50X12.
Stent - Main Branch
Drug-eluting stent was successfully placed. The stent used was a STENT COR L12MM DIA3MM PLATCH ELUTING BIOABS ABL POLY ROUND THIN STRUT LOW PROF SYN XD.
Post-Intervention Lesion Assessment
There is a 0% residual stenosis in the main branch post intervention.
There is a 0% residual stenosis in the side branch post intervention.
Procedure Comments
Procedure Comments Access was obtained in the right rqadial artery with a 6 fr sheath. The left main was engaged with a 6 fr tig catheter. The RCA was engaged with a 6 fr tig catheter.
Heparin was administered and the ACT was monitored during the procedure. The Left Main coronary artery was engaged with a 6Fr EBU 3.5 guiding catheter and the LAD was crossed with a 0.014 inch allstar wire.The diagonal was crossed with a pilot wire. The LAD lesion was dilated with a 3.0 balloon to 12 atm and stented with a 3./3.5 stentsto 18 atm. The diagonal was rewired and ballooned with a 2.5 mm balloonThe radial artery sheath was pulled and hemostasis was achieved with a Terumo TR band. There were no complications during the procedure and the patient was transferred to the Cath Lab Holding Area / 7-1400 in stable condition.
All of your help is appreciated!!
Procedures
Angioplasty - Coronary
Stent DES - Coronary
Percutaneous Coronary Intervention
CORONARY ANGIO WITH POSSIBLE PTCA
Indications
NSTEMI (non-ST elevated myocardial infarction) [I21.4 (ICD-10-CM)]
Pre Procedure Diagnosis
NSTEMI
Case Tracking Events
Event Time In
Moderate Sedation Start 0915
Moderate Sedation End 1008
Conclusion
Two vessel coronary artery disease (LAD,RCA).
Successful percutaneous coronary intervention (drug eluting stenting) of the LAD and the diagonal branch of the LAD.
The patient was monitored continuously 1:1 throughout the entire procedure by me while sedation was administered.
Prep
Vital Signs AUC Assessment:
AUC score: 7
AUC indication: 16
HPI:Indication:
Revascularization by PCI or CABG of 1 or more arteries in a patient with NSTEMI or unstable angina with
Stabilization after presentation
High risk for clinical events
A (7) Indication: 16; Score 7
Vessel Findings
Diagnostic
Dominance: Right
Left Main
The vessel exhibits minimal luminal irregularities.
Left Anterior Descending
Ost LAD to Prox LAD lesion is 90% stenosed with 90% stenosed side branch in 1st Diag.
Left Circumflex
The vessel exhibits minimal luminal irregularities.
Right Coronary Artery
Ost RCA to Mid RCA lesion is 100% stenosed.
Right Posterior Descending Artery
Collaterals
RPDA filled by collaterals from Mid LAD.
Intervention
Ost LAD to Prox LAD lesion with side branch in 1st Diag
Stent - Main Branch
Drug-eluting stent was successfully placed. The stent used was a STENT RESOLUTE ONYX RX 3.00X26.
Stent - Main Branch
Drug-eluting stent was successfully placed. The stent used was a STENT RESOLUTE ONYX RX 3.50X12.
Stent - Main Branch
Drug-eluting stent was successfully placed. The stent used was a STENT COR L12MM DIA3MM PLATCH ELUTING BIOABS ABL POLY ROUND THIN STRUT LOW PROF SYN XD.
Post-Intervention Lesion Assessment
There is a 0% residual stenosis in the main branch post intervention.
There is a 0% residual stenosis in the side branch post intervention.
Procedure Comments
Procedure Comments Access was obtained in the right rqadial artery with a 6 fr sheath. The left main was engaged with a 6 fr tig catheter. The RCA was engaged with a 6 fr tig catheter.
Heparin was administered and the ACT was monitored during the procedure. The Left Main coronary artery was engaged with a 6Fr EBU 3.5 guiding catheter and the LAD was crossed with a 0.014 inch allstar wire.The diagonal was crossed with a pilot wire. The LAD lesion was dilated with a 3.0 balloon to 12 atm and stented with a 3./3.5 stentsto 18 atm. The diagonal was rewired and ballooned with a 2.5 mm balloonThe radial artery sheath was pulled and hemostasis was achieved with a Terumo TR band. There were no complications during the procedure and the patient was transferred to the Cath Lab Holding Area / 7-1400 in stable condition.