Can someon with TAVR Coding experience please Help?

debbyallen

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I have attached the report for the patient I am needing help on. Can someone tell me what codes and modfiers(s) need to be used?


Cardiac Catheterization TAVR Operative Report
Referring Physicians:
Primary Operator:
Date of procedure: 05/11/2021
Cardiac Cath Lab OPERATIVE REPORT- TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR), percutaneous,
transfemoral approach.
Implant Device Name/Size: Successful TAVR implant with Edwards Sapien Ultra _23_ mm valve
Serial #
Model #:Sapien Ultra 23 mm valve
Procedure: Transcatheter Aortic Valve Replacement (TAVR)
Sedation method: General Anesthesia with Endotracheal Intubation (please refer to Anesthesia procedure report)
PRE-OP DIAGNOSIS:
symptomatic severe aortic stenosis
POST-OP DIAGNOSIS:
same
S/P TAVR (transcatheter aortic valve replacement), bioprosthetic
NAME OF PROCEDURES:
1. Right and left common femoral arterial access.
2. Left common femoral venous access.
4. Placement of a transvenous temporary Pacemaker into the Right Ventricle.
5. Placement of a pigtail catheter into the aortic root
6. Interpretation of pre-, intra- and post - operative transesophageal echocardiographic images.
6. Aortic Arteriography, multiple times.
Printed on: 05/21/2021 15:06 PDT
Page 1 of 4
Cardiology Procedure
* Final Report *
7. Transcatheter aortic valve replacement completed using a Edwards Sapien Ultra _23_ mm aortic bioprosthesis (right common
femoral percutaneous approach).
8. Dual Perclose ProGlide used for successful right common femoral arterial closure and hemostasis. Left CFA and CFV closed
with Perclose.
PRIMARY OPERATOR: terventional and Structural Cardiologist)
CO-SURGEON: (Cardiothoracic Surgery)
ANESTHESIA: please see anesthesia report
ESTIMATED BLOOD LOSS: 40 cc
ESTIMATED CONTRAST USED: please see TAVR procedural log
FINDINGS/OPERATIVE Procedure:
After written informed consent was obtained from the patient, patient was brought to cardiac catheterization lab in a fasting
state. Bilateral groins and chest wall were prepped and draped in usual sterile fashion. Under ultrasound guidance 2% lidocaine
was administered to the right and left groin. We then obtained access to the right common femoral artery using a micropuncture
system exchanging for a micropuncture sheath which was then confirmed on fluoroscopy. We then placed a 6 French sheath.
Right common femoral angiogram was performed. Attention was then placed on the left common femoral artery under
ultrasound guidance access obtained to the left common femoral artery using a micropuncture system. Micropuncture system
exchanged for a 6 French sheath. Left common femoral angiogram performed. Left common femoral venous access
obtained and exchanged with Seldinger technique for a 6 French sheath.
Two preclose sutures were then placed in the right common femoral artery over a J-wire. We then placed a
multipurpose catheter over a J-wire into the descending aorta. The wire was removed and replaced with a Lunderquist stiff wire.
The sheath was then removed along with the catheter we then did subsequent dilation using a 10, 12 French sheath and then
the Edwards sheath dilator. We then advanced the Edwards commander sheath without any complications. Fluoroscopy was
used to guide the sheath. Sheath was then sutured into place.
Pigtail catheter was advanced over a J-wire and the left common femoral arterial sheath and placed into the right coronary cusp.
The wire was then removed. Pacing wire was then placed into the right ventricle with appropriate capture and thresholds
obtained. Aortic root angiogram in the coplanar view was then obtained.
Using AL-1 diagnostic catheter over a J-wire we advanced the catheter into the aortic root the wire was then removed and
flushed. We then crossed the aortic valve with a straight wire. The AL-1 diagnostic catheter was advanced into the left
ventricle. The straight wire was removed pigtail catheter was advanced into the apex. We then obtained left ventricular
pressures. A safari wire was then advanced into the apex and the catheter was then removed.
We then advanced the Sapien Ultra valve into the sheath and pulled the balloon down into the valve in the descending aorta.
Further fine tuning was used to bring the balloon inline with the valve. After giving enough flexion, under LAO imaging, the valve
was brought around the arch and across the valve. The push catheter was pulled back to the second marker. Aortic root
angiogram performed to confirm our location.
Breaths held, pacing initiated until cardiac standstill achieved, aortic root angiogram performed, valve deployed successfully at
nominal pressures. Balloon then removed to descending aorta. Aortic root angiogram performed confirming no aortic
regurgitation and patent coronary flow. TEE used to confirm regurgitation. Wire removed along with delivery system.
Pacing wire removed. Pigtail catheter brought down to aortic bifurcation. J-wire advanced across the E-sheath. Sheath removed
and Perclose sutures deployed. Wire then removed. Aortic runoff performed confirming no extravasation. Pressure held over R
groin.
Printed on: 05/21/2021 15:06 PDT
Page 2 of 4
Cardiology Procedure
* Final Report *
Perclose deployed to L common femoral arterial sheath and venous sheaths. Manual pressure held.
Protamine given and anesthesia reversed. Patient extubated and transferred onto transport bed.
COMPLICATIONS:
None
SPECIMENS REMOVED:
None
ADDITIONAL STUDIES ORDERED:
Immediately post-op performed a limited TTE to assess valve hemodynamics. As per protocol, patient will have a repeat
comprehensive echo within 24 hours post TAVR procedure to evaluate cardiac and valvular function.
DISPOSITION:
ICU
IMPRESSION:
1. Successful TAVR procedure in the cardiac cath lab, implantation of a Edwards Sapien Ultra _23__ mm valve. Patient extubated
in the cath lab, woke up and moving all extremities and responding to commands. No complications.
DISCUSSION AND RECOMMENDATIONS:
- Routine post-TAVR care s/p transfemoral access and right groin closed with Perclose closure device. Left groin arterial and
venous sheaths were closed with Perclose closure device.
- Patient to admit to ICU bed.
- monitor for bleeding and cerebrovascular complications.
- Monitoring of hemodynamics.
- Goal SBP <160 mmHg
- Plavix 300mg loading in the ICU. ASA 81 daily. Holding cardiac home medications today. Will resume likely tomorrow.
- Plavix 75mg PO daily starting tomorrow.
- No ECG changes noted immediately post TAVR. will monitor in the ICU. Pacing wire was removed.
- ECG in the ICU.
- CBC and Chem panel in the ICU.
- PT/OT evaluation tomorrow.
- Planned to ambulate later tonight after 6 hours bed rest post procedure.
- Complete ECHO tomorrow on POD #1.
- Cardiac Rehab evaluation tomorrow please.
- Planned D/C to home on POD #2 barring from any complications.
Printed on: 05/21/2021 15:06 PDT
Page 3 of 4
 

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mk2001

Guru
Messages
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Best answers
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I have attached the report for the patient I am needing help on. Can someone tell me what codes and modfiers(s) need to be used?


Cardiac Catheterization TAVR Operative Report
Referring Physicians:
Primary Operator:
Date of procedure: 05/11/2021
Cardiac Cath Lab OPERATIVE REPORT- TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR), percutaneous,
transfemoral approach.
Implant Device Name/Size: Successful TAVR implant with Edwards Sapien Ultra _23_ mm valve
Serial #
Model #:Sapien Ultra 23 mm valve
Procedure: Transcatheter Aortic Valve Replacement (TAVR)
Sedation method: General Anesthesia with Endotracheal Intubation (please refer to Anesthesia procedure report)
PRE-OP DIAGNOSIS:
symptomatic severe aortic stenosis
POST-OP DIAGNOSIS:
same
S/P TAVR (transcatheter aortic valve replacement), bioprosthetic
NAME OF PROCEDURES:
1. Right and left common femoral arterial access.
2. Left common femoral venous access.
4. Placement of a transvenous temporary Pacemaker into the Right Ventricle.
5. Placement of a pigtail catheter into the aortic root
6. Interpretation of pre-, intra- and post - operative transesophageal echocardiographic images.
6. Aortic Arteriography, multiple times.
Printed on: 05/21/2021 15:06 PDT
Page 1 of 4
Cardiology Procedure
* Final Report *
7. Transcatheter aortic valve replacement completed using a Edwards Sapien Ultra _23_ mm aortic bioprosthesis (right common
femoral percutaneous approach).
8. Dual Perclose ProGlide used for successful right common femoral arterial closure and hemostasis. Left CFA and CFV closed
with Perclose.
PRIMARY OPERATOR: terventional and Structural Cardiologist)
CO-SURGEON: (Cardiothoracic Surgery)
ANESTHESIA: please see anesthesia report
ESTIMATED BLOOD LOSS: 40 cc
ESTIMATED CONTRAST USED: please see TAVR procedural log
FINDINGS/OPERATIVE Procedure:
After written informed consent was obtained from the patient, patient was brought to cardiac catheterization lab in a fasting
state. Bilateral groins and chest wall were prepped and draped in usual sterile fashion. Under ultrasound guidance 2% lidocaine
was administered to the right and left groin. We then obtained access to the right common femoral artery using a micropuncture
system exchanging for a micropuncture sheath which was then confirmed on fluoroscopy. We then placed a 6 French sheath.
Right common femoral angiogram was performed. Attention was then placed on the left common femoral artery under
ultrasound guidance access obtained to the left common femoral artery using a micropuncture system. Micropuncture system
exchanged for a 6 French sheath. Left common femoral angiogram performed. Left common femoral venous access
obtained and exchanged with Seldinger technique for a 6 French sheath.
Two preclose sutures were then placed in the right common femoral artery over a J-wire. We then placed a
multipurpose catheter over a J-wire into the descending aorta. The wire was removed and replaced with a Lunderquist stiff wire.
The sheath was then removed along with the catheter we then did subsequent dilation using a 10, 12 French sheath and then
the Edwards sheath dilator. We then advanced the Edwards commander sheath without any complications. Fluoroscopy was
used to guide the sheath. Sheath was then sutured into place.
Pigtail catheter was advanced over a J-wire and the left common femoral arterial sheath and placed into the right coronary cusp.
The wire was then removed. Pacing wire was then placed into the right ventricle with appropriate capture and thresholds
obtained. Aortic root angiogram in the coplanar view was then obtained.
Using AL-1 diagnostic catheter over a J-wire we advanced the catheter into the aortic root the wire was then removed and
flushed. We then crossed the aortic valve with a straight wire. The AL-1 diagnostic catheter was advanced into the left
ventricle. The straight wire was removed pigtail catheter was advanced into the apex. We then obtained left ventricular
pressures. A safari wire was then advanced into the apex and the catheter was then removed.
We then advanced the Sapien Ultra valve into the sheath and pulled the balloon down into the valve in the descending aorta.
Further fine tuning was used to bring the balloon inline with the valve. After giving enough flexion, under LAO imaging, the valve
was brought around the arch and across the valve. The push catheter was pulled back to the second marker. Aortic root
angiogram performed to confirm our location.
Breaths held, pacing initiated until cardiac standstill achieved, aortic root angiogram performed, valve deployed successfully at
nominal pressures. Balloon then removed to descending aorta. Aortic root angiogram performed confirming no aortic
regurgitation and patent coronary flow. TEE used to confirm regurgitation. Wire removed along with delivery system.
Pacing wire removed. Pigtail catheter brought down to aortic bifurcation. J-wire advanced across the E-sheath. Sheath removed
and Perclose sutures deployed. Wire then removed. Aortic runoff performed confirming no extravasation. Pressure held over R
groin.
Printed on: 05/21/2021 15:06 PDT
Page 2 of 4
Cardiology Procedure
* Final Report *
Perclose deployed to L common femoral arterial sheath and venous sheaths. Manual pressure held.
Protamine given and anesthesia reversed. Patient extubated and transferred onto transport bed.
COMPLICATIONS:
None
SPECIMENS REMOVED:
None
ADDITIONAL STUDIES ORDERED:
Immediately post-op performed a limited TTE to assess valve hemodynamics. As per protocol, patient will have a repeat
comprehensive echo within 24 hours post TAVR procedure to evaluate cardiac and valvular function.
DISPOSITION:
ICU
IMPRESSION:
1. Successful TAVR procedure in the cardiac cath lab, implantation of a Edwards Sapien Ultra _23__ mm valve. Patient extubated
in the cath lab, woke up and moving all extremities and responding to commands. No complications.
DISCUSSION AND RECOMMENDATIONS:
- Routine post-TAVR care s/p transfemoral access and right groin closed with Perclose closure device. Left groin arterial and
venous sheaths were closed with Perclose closure device.
- Patient to admit to ICU bed.
- monitor for bleeding and cerebrovascular complications.
- Monitoring of hemodynamics.
- Goal SBP <160 mmHg
- Plavix 300mg loading in the ICU. ASA 81 daily. Holding cardiac home medications today. Will resume likely tomorrow.
- Plavix 75mg PO daily starting tomorrow.
- No ECG changes noted immediately post TAVR. will monitor in the ICU. Pacing wire was removed.
- ECG in the ICU.
- CBC and Chem panel in the ICU.
- PT/OT evaluation tomorrow.
- Planned to ambulate later tonight after 6 hours bed rest post procedure.
- Complete ECHO tomorrow on POD #1.
- Cardiac Rehab evaluation tomorrow please.
- Planned D/C to home on POD #2 barring from any complications.
Printed on: 05/21/2021 15:06 PDT
Page 3 of 4
33361,62,Q0
I35.0 & Z00.6
CT (Clinical Trial) #01737528
 
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