Wiki Broken & Embolized Catheter in LV During Heart Cath - Can This Complication Be Coded?

mcauffman86

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During one of my physician's heart cath procedures, the catheter broke off into the left ventricle and embolized and had to be retrieved via snare. Is this a complication that I can code for? Any thoughts?





Procedure Performed:


Right and Left heart catheterization with coronary angiogram

Langston catheter retrieval using a 6 French snare


Name of Procedure:


1. Right heart catheterization using a 7.5-French Swan-Ganz floatation catheter.

2. Left heart catheterization using a 6-French Pigtail catheter.

3. Left ventricular cine angiogram using a 6-French Pigtail catheter.

4. Selective coronary angiogram using a 6L4 and 6R4 Judkins catheters.

5. Langston inner catheter was embolized to the LV during left ventriculogram requiring urgent catheter retrieval with a 6 F-12 mm Snare.



Description of Procedure:

The patient was premedicated with Versed and fentanyl and was brought into the cath lab in a fasting state. Lidocaine 1% was used as a local anesthetic. After the right groin was anesthetized, vascular access was achieved without difficulty using a Lumify vascular US systems as follows:



Ultrasound guided vascular access was performed using the Lumify vascular system.
The left common femoral artery and vein were identified by Ultrasound above the profunda femoral branch.
The vessel demonstrated good color flow and appears suitable for vascular access.
Real time live visualization of vascular needle entry and direct puncture into the left common femoral artery and vein was performed to ensure safe access to the vessel without double puncture.
Vascular access was achieved with a single puncture without difficulty.  A 7 french arterial sheath and an 8F venous sheath were introduced safely with Ultrasound guidance. There are no complications.




A 7.5-French Swan-Ganz floatation catheter was advanced into the pulmonary artery position for hemodynamic monitoring. A 6-French Pigtail catheter was then advanced into the left ventricle. Left

ventricular cineangiogram was performed using the 6-French Pigtail catheter without complications. Selective coronary angiogram was performed using a 6L4 and a 6R4 Judkins catheters.



During left ventriculogram, the inner catheter of the Langston double-lumen catheter broke off and embolized and coiled up into the left ventricle.
We were able to promptly retrieve the Langston inner catheter with a 6 French 12 mm snare without complication.


The patient tolerated the procedure well and was transferred to CVL recovery for post cath management.



Moderate sedation performed using IV Versed and Fentanyl.

Patient received continuous EKG, hemodynamic and oximetry monitoring.
The attending physician was present and/or scrubbed for the entire procedures.
Duration: 54 minutes.
Total moderate sedation duration = 54 min. .




Hemodynamics:

Aortic pressure was:​
2/6/2020​
2/6/2020​
2/6/2020​
AO Systolic Pressure
121​
148​
125​
AO Diastolic Pressure
66​
69​
60​
AO Mean Pressure
89​
102​
87​



LV pressure and LVEDP was:​
2/6/2020​
LV Systolic Pressure
144​
LV Diastolic Pressure
67​
LV End Diastolic Pressure
77​
Some recent data might be hidden​


Right Heart Catheterization Hemodynamic Data:

Right Heart Hemodynamics:​
2/6/2020​
Right Atrium Mean Pressure
13​
Right Ventricular Systolic Pressure
46​
Right Ventricular Diastolic Pressure
11​
Right Ventricular End Diastolic
15​
Pulmonary Artery Systolic Pressure
41​
Pulmonary Artery Diastolic Pressure
23​
Pulmonary Artery Mean Pressure
29​
Pulmonary Capillary Wedge Pressure
18​


Cardiac output is estimated at 4.5 by thermodilution technique.
There is a mean transaortic gradient of 47 mmHg consistent with severe aortic stenosis



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Fluoroscopy:

Demonstrated normal cardiac silhouette with visible coronary calcification.

There is visible stent in the LAD.



There are severe aortic valve calcification.



The right groin sheath was removed using Angio-Seal closure device manuel pressure with good hemostasis and without complication.



Cine Interpretation:


Dominance, right dominance.

The left main coronary artery branches into LAD and circumflex. No significant disease is seen in the left main trunk.

The left anterior descending artery gives off diagonal branches.  The mid LAD stent appeared to be patent without restenosis There is 50% distal LAD stenosis.

The circumflex artery gives off obtuse marginal branchs. There is 70% proximal circumflex stenosis no siignificant disease in the circumflex artery.

The right coronary artery gives off PDA and posterolateral segment. There is 99-100% occlusion of the mid right coronary artery with bridging collaterals.



Left ventricular cineangiogram revealed normal left ventricular systolic function.



Case Classification:


Elective/Scheduled



Stress or Imaging Test Performed:

The following procedure or procedures were reviewed:​
2/5/2020​
Imaging modality used:
Echo​


Anginal Class:

Anti-Anginal Meds:

Anti-Anginal Meds within two weeks:​
2/5/2020​
Meds
Beta Blocker;ACE Inhibitor;Lipid lowering agent;Platelet aggregation inhibitor​




FluoroTime and Dose:

      
Radiation Tracking
 
Event
Details
User
No information to display​


Complications:
Langston inner catheter was embolized to the LV during left ventriculogram requiring urgent catheter retrieval with a 6 F-12 mm Snare.
Estimated Blood Loss:

Minimal



Final Impression:


Coronary angiogram demsevere two-vessel coronary disease with severe aortic stenosis.

Right & Left heart cath and coronary angiogram was performed without complication.



Recommendation:
Patient is at increased risk for coronary bypass surgery and surgical AVR due to elderly age and increased frailty.

Case was discussed with the patient and family.

We'll consider stage PCI followed by evaluation for transcatheter aortic valve replacement.


 
Awesome Question!
Yes you may report 37197 in addition to 93460- Selective Right and Left heart cath w/ coronary angiography . Since 93460 has higher RVU we code this case- 93460, 37197-XU
 
So I would say due to the description of what code T82.598A, indicates I would instead assign code T82.599A. Other mechanical complication of unspecified cardiac and vascular devices and implants, initial encounter.
 
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