stgregor
Networker
Can someone please check my coding for this case? I'm coding for the physician (professional component). I have:
93510-26
93545
93543
93555-26-59
93556-26-59
92950
92980-RC
PROCEDURE:
1. Diagnostic cardiac catheterization.
2. Selective coronary arteriography.
3. Contrast left ventriculography.
4. Emergent drug-eluting coronary stent implants, dominant right coronary artery.
DESCRIPTION OF PROCEDURE; The patient was brought to the Cardiac
Catheterization Laboratory urgently with an ongoing inferior ST segment myocardial infarction. Diagnostic cardiac catheterization was performed, first using a 6 French, Judkins left-4 and right-4 diagnostic catheters from the right femoral approach. The patient was in sinus bradycardia with PVCs during the catheterization and was borderline hypotensive with a systolic blood pressure of 90. He otherwise did not have hemodynamic instability during the diagnostic portion of the procedure.
FINDINGS:
CORONARY ARTERIOGRAPHY: The right coronary artery is dominant and occluded 1-cm beyond the ostium. The ostium also possesses a significant 70% discrete stenosis at the aorto-ostial junction. The left main coronary artery possesses a mild 20 to 30% ostial narrowing. The distal left main bifurcation also possesses mild 20 to 30% disease involving the origin of the circumflex coronary artery. The circumflex coronary artery is anatomically
nondominant and possesses luminal irregularities in the AV groove, as well as in the first marginal branch, not exceeding 20 to 30%. The left anterior descending coronary artery is large, showing just minimal luminal irregularities, not exceeding 10 to 20%. No critical disease was identified in the left coronary circulation.
After the diagnostic coronary arteriogram, the right coronary ostium was engaged with a 6 French guiding catheter. Heparin was supplemented to the original dose given in the emergency department to achieve an activated clotting time of greater than 200 seconds. Abciximab was also administered for the intervention.
The proximal right coronary stenosis was crossed difficulty using a run-through guidewire. Balloon angioplasty was then performed to achieve reperfusion using a 3.5-mm x 15-mm Maverick balloon.
Following reperfusion, the patient suffered a ventricular fibrillatory arrest, which required defibrillation on three occasions. The patient remained hemodynamically unstable until the ostial and proximal disease of the right coronary artery could be reopened with stent implants.
The proximal lesion was treated first with a 4-mm x 28-mm Promus stent by inflation of the stent delivery balloon to 16 atmospheres of pressure. Follow-up angiography showed a good result at that lesion site, although there was evidence for downstream either spasm or intramural hematoma compressing the lumen distal to the stent. The midvessel was then stented with a second overlapping 4-mm x 28-mm Promus stent by inflation of the stent delivery balloon to 18 atmospheres of pressure.
Finally, the ostium was stented with a 4-mm x 12-mm Promus stent by inflation of the stent delivery balloon to 18 atmospheres of pressure.
Follow-up contrast arteriography showed excellent results throughout the ostium, proximal and mid vessel, with residual stenoses of 0%. The TIMI flow grade postintervention was III.
There were just a very small distal clots present in the PDA and LD branches without dye staining post-intervention, which were not chased with emboli extraction catheters, as they were in the buried terminal branches. There was no abnormal myocardial staining or blush to suggest capillary plugging
postintervention.
Following the intervention, the patient's electrical and hemodynamic condition stabilized. Left ventriculography was then performed in the LAO and RAO projections. This demonstrated minimal inferolateral hypokinesis with an overall
well-maintained ejection fraction of 55%.
At the conclusion of the procedure, the right femoral sheath was removed successfully using a 6 French Angio-Seal device.
CONCLUSIONS:
1. Acute inferior ST segment elevation, secondary to thrombotic occlusion of the proximal dominant right coronary artery with additional associated 70% ostial stenosis and downstream significant disease midvessel.
2. Status post Promus drug-eluting stent implants to the ostium, proximal and mid right coronary artery (total of three Promus stents), all 4-mm diameter with a total stent length of 68-mm with ultimate stenosis reductions from 100% to 0%,
3. Minimal luminal irregularities of the left coronary artery, generally not exceeding 20%.
4. Minimal inferolateral hypokinesis of the left ventricle post-intervention with estimated ejection fraction of 55%.
5. Procedure complicated by ventricular fibrillation upon reperfusion of the right coronary artery requiring defibrillation on three occasions.
6. No further complications.
93510-26
93545
93543
93555-26-59
93556-26-59
92950
92980-RC
PROCEDURE:
1. Diagnostic cardiac catheterization.
2. Selective coronary arteriography.
3. Contrast left ventriculography.
4. Emergent drug-eluting coronary stent implants, dominant right coronary artery.
DESCRIPTION OF PROCEDURE; The patient was brought to the Cardiac
Catheterization Laboratory urgently with an ongoing inferior ST segment myocardial infarction. Diagnostic cardiac catheterization was performed, first using a 6 French, Judkins left-4 and right-4 diagnostic catheters from the right femoral approach. The patient was in sinus bradycardia with PVCs during the catheterization and was borderline hypotensive with a systolic blood pressure of 90. He otherwise did not have hemodynamic instability during the diagnostic portion of the procedure.
FINDINGS:
CORONARY ARTERIOGRAPHY: The right coronary artery is dominant and occluded 1-cm beyond the ostium. The ostium also possesses a significant 70% discrete stenosis at the aorto-ostial junction. The left main coronary artery possesses a mild 20 to 30% ostial narrowing. The distal left main bifurcation also possesses mild 20 to 30% disease involving the origin of the circumflex coronary artery. The circumflex coronary artery is anatomically
nondominant and possesses luminal irregularities in the AV groove, as well as in the first marginal branch, not exceeding 20 to 30%. The left anterior descending coronary artery is large, showing just minimal luminal irregularities, not exceeding 10 to 20%. No critical disease was identified in the left coronary circulation.
After the diagnostic coronary arteriogram, the right coronary ostium was engaged with a 6 French guiding catheter. Heparin was supplemented to the original dose given in the emergency department to achieve an activated clotting time of greater than 200 seconds. Abciximab was also administered for the intervention.
The proximal right coronary stenosis was crossed difficulty using a run-through guidewire. Balloon angioplasty was then performed to achieve reperfusion using a 3.5-mm x 15-mm Maverick balloon.
Following reperfusion, the patient suffered a ventricular fibrillatory arrest, which required defibrillation on three occasions. The patient remained hemodynamically unstable until the ostial and proximal disease of the right coronary artery could be reopened with stent implants.
The proximal lesion was treated first with a 4-mm x 28-mm Promus stent by inflation of the stent delivery balloon to 16 atmospheres of pressure. Follow-up angiography showed a good result at that lesion site, although there was evidence for downstream either spasm or intramural hematoma compressing the lumen distal to the stent. The midvessel was then stented with a second overlapping 4-mm x 28-mm Promus stent by inflation of the stent delivery balloon to 18 atmospheres of pressure.
Finally, the ostium was stented with a 4-mm x 12-mm Promus stent by inflation of the stent delivery balloon to 18 atmospheres of pressure.
Follow-up contrast arteriography showed excellent results throughout the ostium, proximal and mid vessel, with residual stenoses of 0%. The TIMI flow grade postintervention was III.
There were just a very small distal clots present in the PDA and LD branches without dye staining post-intervention, which were not chased with emboli extraction catheters, as they were in the buried terminal branches. There was no abnormal myocardial staining or blush to suggest capillary plugging
postintervention.
Following the intervention, the patient's electrical and hemodynamic condition stabilized. Left ventriculography was then performed in the LAO and RAO projections. This demonstrated minimal inferolateral hypokinesis with an overall
well-maintained ejection fraction of 55%.
At the conclusion of the procedure, the right femoral sheath was removed successfully using a 6 French Angio-Seal device.
CONCLUSIONS:
1. Acute inferior ST segment elevation, secondary to thrombotic occlusion of the proximal dominant right coronary artery with additional associated 70% ostial stenosis and downstream significant disease midvessel.
2. Status post Promus drug-eluting stent implants to the ostium, proximal and mid right coronary artery (total of three Promus stents), all 4-mm diameter with a total stent length of 68-mm with ultimate stenosis reductions from 100% to 0%,
3. Minimal luminal irregularities of the left coronary artery, generally not exceeding 20%.
4. Minimal inferolateral hypokinesis of the left ventricle post-intervention with estimated ejection fraction of 55%.
5. Procedure complicated by ventricular fibrillation upon reperfusion of the right coronary artery requiring defibrillation on three occasions.
6. No further complications.