Billing selective bilateral renal artery angio with cardiac cath

dwoody

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CARDIAC CATHETERIZATION REPORT

HISTORY: The patient is a 51-year-old Caucasian female with prior stenting to her LAD who presents with chest pain.

PHYSICAL EXAMINATION: GENERAL: She is morbidly obese.
CARDIAC: Normal S1, S2.
LUNGS: Generally diminished in the bases.
ABDOMEN: Soft.
EXTREMITIES: She has 1+ pulses.

VASCULAR ACCESS: A 5-French sheath in the right femoral artery introduced using the modified Seldinger technique.

PROCEDURES PERFORMED:
1. Left heart catheterization.
2. Selective coronary angiography.
3. Left ventriculogram.
4. Bilateral selective renal angiography.
5. Physiologic measurement of the LAD.

ANGIOGRAPHIC CATHETERS USED: Standard catheters, a pigtail and a 6-French CLS-3.5 guide.

HEMODYNAMICS: Ascending aortic pressure was 160/80. Left ventricular pressure was 160/26.

LEFT VENTRICULOGRAM: Left ventriculogram obtained in the standard RAO projection revealed normal wall motion with an estimated ejection fraction of 60%. There was no significant mitral regurgitation.

BILATERAL SELECTIVE RENAL ANGIOGRAPHY: Renal angiography performed revealed mild plaquing on the left and 20% to 30% stenosis on the right.

SELECTIVE CORONARY ANGIOGRAPHY: The left main coronary artery was angiographically free of stenosis. The left anterior descending coronary artery had an ostial 30% stenosis and there were stents in the midportion of the LAD which were patent. There appeared to be a 40% focal in-stent restenosis. The left circumflex artery was a large dominant vessel with the major marginal branch having an ostial 30% to 40% stenosis. The right coronary artery was small, nondominant without significant obstructive disease.

PHYSIOLOGIC MEASUREMENT: Undertaken to the LAD. A 0.014-inch RADI wire was equalized in the aorta. Weight-adjusted heparin had already been given, and a 6-French CLS-3.5 guide was used to cannulate the left coronary artery. The RADI wire was directed into the distal part of the LAD, 240 mcg of adenosine was given to achieve maximal hyperemia, and the FFR was noted to be 0.90 consistent with nonflow-limiting disease. Angiography noted after completion of physiologic measurement revealed unchanged anatomy, no evidence of dissection and TIMI 3 flow.

The patient tolerated the procedure well. The arteriotomy site was sealed using an Angio-Seal closure device. Manual compression was held. The patient was given prophylactic antibiotics, and the groin was reprepped and draped.

FINAL INTERPRETATION:
1. Patent left anterior descending stents with mild to intermediate in-stent restenosis. This is deemed to be not flow limiting per physiologic measurement. 2. Normal left ventricular function.
3. No significant renal artery stenosis.
4. Systemic hypertension.
5. Aggressive medical therapy.


Is there enough documentation to bill 36252? And should there be a 59 modifier on this or not. I am getting conflicting info on this. Thanks
 

Jim Pawloski

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CARDIAC CATHETERIZATION REPORT

HISTORY: The patient is a 51-year-old Caucasian female with prior stenting to her LAD who presents with chest pain.

PHYSICAL EXAMINATION: GENERAL: She is morbidly obese.
CARDIAC: Normal S1, S2.
LUNGS: Generally diminished in the bases.
ABDOMEN: Soft.
EXTREMITIES: She has 1+ pulses.

VASCULAR ACCESS: A 5-French sheath in the right femoral artery introduced using the modified Seldinger technique.

PROCEDURES PERFORMED:
1. Left heart catheterization.
2. Selective coronary angiography.
3. Left ventriculogram.
4. Bilateral selective renal angiography.
5. Physiologic measurement of the LAD.

ANGIOGRAPHIC CATHETERS USED: Standard catheters, a pigtail and a 6-French CLS-3.5 guide.

HEMODYNAMICS: Ascending aortic pressure was 160/80. Left ventricular pressure was 160/26.

LEFT VENTRICULOGRAM: Left ventriculogram obtained in the standard RAO projection revealed normal wall motion with an estimated ejection fraction of 60%. There was no significant mitral regurgitation.

BILATERAL SELECTIVE RENAL ANGIOGRAPHY: Renal angiography performed revealed mild plaquing on the left and 20% to 30% stenosis on the right.

SELECTIVE CORONARY ANGIOGRAPHY: The left main coronary artery was angiographically free of stenosis. The left anterior descending coronary artery had an ostial 30% stenosis and there were stents in the midportion of the LAD which were patent. There appeared to be a 40% focal in-stent restenosis. The left circumflex artery was a large dominant vessel with the major marginal branch having an ostial 30% to 40% stenosis. The right coronary artery was small, nondominant without significant obstructive disease.

PHYSIOLOGIC MEASUREMENT: Undertaken to the LAD. A 0.014-inch RADI wire was equalized in the aorta. Weight-adjusted heparin had already been given, and a 6-French CLS-3.5 guide was used to cannulate the left coronary artery. The RADI wire was directed into the distal part of the LAD, 240 mcg of adenosine was given to achieve maximal hyperemia, and the FFR was noted to be 0.90 consistent with nonflow-limiting disease. Angiography noted after completion of physiologic measurement revealed unchanged anatomy, no evidence of dissection and TIMI 3 flow.

The patient tolerated the procedure well. The arteriotomy site was sealed using an Angio-Seal closure device. Manual compression was held. The patient was given prophylactic antibiotics, and the groin was reprepped and draped.

FINAL INTERPRETATION:
1. Patent left anterior descending stents with mild to intermediate in-stent restenosis. This is deemed to be not flow limiting per physiologic measurement. 2. Normal left ventricular function.
3. No significant renal artery stenosis.
4. Systemic hypertension.
5. Aggressive medical therapy.


Is there enough documentation to bill 36252? And should there be a 59 modifier on this or not. I am getting conflicting info on this. Thanks
I think there is enough info for 36252, but don't use modifier 59 because the charge is for bilateral renals.
HTH,
Jim Pawloski, CIRCC
 
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Yes you should use 93458-26 36252-59 and 93571 (for the ffr). The only thing I see that I dont really like is giving the doc credit for saying "selective" for the renals. It would be best if the docs would actually say they placed the cath into the ostium of the renal left then right. But many don't. I believe there will be an article soon telling us to add the 59 modifier to the renal like we used to have to. Might as well add it now.
 
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