Cardiac catheterization report

jonyleo20

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CARDIAC CATHETERIZATION REPORT

DATE OF PROCEDURE: 05/16/2012

REFERRING PHYSICIAN:
PROCEDURE:
1. Right heart catheterization.
2. Left heart catheterization.
3. Right iliofemoral angiogram.
4. Supravalvular aortogram.
5. Angio-Seal closure device placement.

BRIEF HISTORY AND INDICATION:
Patient is a 75-year-old male with a history of aortic
insufficiency. I have been asked to perform right and left heart
catheterization as well as aortography prior to consideration for
cardiac surgery.

All risks, benefits, and alternatives were discussed at length with
the patient. Patient refuses anything other than diagnostic testing
today. Refuses intervention. Refuses intracoronary evaluation.

RIGHT HEART CATHETERIZATION FINDINGS:
1. Right atrium - mean 11 mmHg.
2. Right ventricle - 32/10.
3. Pulmonary artery - 32/19 with a mean 23 mmHg.
4. Pulmonary capillary wedge - mean 19 mmHg.
5. Cardiac output - 4.6 L/minute.

LEFT HEART CATHETERIZATION FINDINGS:
1. Left main - the left main coronary artery has luminal
irregularities and minor eccentric plaque at the origin with no
significant focal stenosis.
2. Left anterior descending - the LAD is a moderately calcified
vessel in its proximal segment. This proximal segment has an
approximate 60 percent stenosis. This is an ectatic diffusely
diseased vessel with sluggish flow distal to the lesion. The main
diagonal branch has luminal irregularities only and no significant
focal obstruction.
3. Left circumflex - the left circumflex artery and its marginal
branches have luminal irregularities throughout but no significant
focal obstruction.
4. Right coronary artery - the RCA has luminal irregularities
throughout its course and is also an ectatic vessel in its
proximal segment, but has no significant focal stenosis. The RCA
is the dominant vessel.
5. Left ventricle -
a. End diastolic pressure 17 mmHg.
b. Ejection fraction visually estimated at 50-55 percent.
c. No aortic stenosis.
d. No significant mitral regurgitation is seen.
6. Supravalvular aortogram - normal system. No aneurysm. No
dissection. No significant aortic insufficiency seen.
7. Right iliofemoral angiogram - normal visualized system. Minimal
atherosclerosis. Sheath enters at an appropriate level. An
Angio-Seal closure device was placed achieving hemostasis.

ASSESSMENT:
1. Essentially normal intracardiac pressures.
2. Coronary artery disease with borderline stenosis in the proximal
to mid left anterior descending (LAD).
3. No significant valvular abnormalities seen.




Can someone please give me an insight on how to code this report .

thx
 

WendyLWest

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Cardiac Cath Report

I would code the cath procedure as 93460 and 93567 for sure. Now my question is for the iliofemoral angio. I'm assuming it would be the extremity angio which would be 75710 but the documentation on this is really not that clear. So this is how I came up with the codes. 93460 which is the Right and Left heart cath codes with the coronories. This code also is used if the LV gram is done which it looks to me that this was done on the example. The left heart cath is verified by the 1. documentation of the report. The coronaries are addressed by numbers 2,3 and 4. You can pick up the Right heart cath by the findings that are listed. The LV is listed with number 5. Number 6 is for the supravalvular aortogram 93567 and the extremity angio is listed under number 7. You will need to modify the diagnostic extremity exam but I hope this helps!
 

dpeoples

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CARDIAC CATHETERIZATION REPORT

DATE OF PROCEDURE: 05/16/2012

REFERRING PHYSICIAN:
PROCEDURE:
1. Right heart catheterization.
2. Left heart catheterization.
3. Right iliofemoral angiogram.
4. Supravalvular aortogram.
5. Angio-Seal closure device placement.

BRIEF HISTORY AND INDICATION:
Patient is a 75-year-old male with a history of aortic
insufficiency. I have been asked to perform right and left heart
catheterization as well as aortography prior to consideration for
cardiac surgery.

All risks, benefits, and alternatives were discussed at length with
the patient. Patient refuses anything other than diagnostic testing
today. Refuses intervention. Refuses intracoronary evaluation.

RIGHT HEART CATHETERIZATION FINDINGS:
1. Right atrium - mean 11 mmHg.
2. Right ventricle - 32/10.
3. Pulmonary artery - 32/19 with a mean 23 mmHg.
4. Pulmonary capillary wedge - mean 19 mmHg.
5. Cardiac output - 4.6 L/minute.

LEFT HEART CATHETERIZATION FINDINGS:
1. Left main - the left main coronary artery has luminal
irregularities and minor eccentric plaque at the origin with no
significant focal stenosis.
2. Left anterior descending - the LAD is a moderately calcified
vessel in its proximal segment. This proximal segment has an
approximate 60 percent stenosis. This is an ectatic diffusely
diseased vessel with sluggish flow distal to the lesion. The main
diagonal branch has luminal irregularities only and no significant
focal obstruction.
3. Left circumflex - the left circumflex artery and its marginal
branches have luminal irregularities throughout but no significant
focal obstruction.
4. Right coronary artery - the RCA has luminal irregularities
throughout its course and is also an ectatic vessel in its
proximal segment, but has no significant focal stenosis. The RCA
is the dominant vessel.
5. Left ventricle -
a. End diastolic pressure 17 mmHg.
b. Ejection fraction visually estimated at 50-55 percent.
c. No aortic stenosis.
d. No significant mitral regurgitation is seen.
6. Supravalvular aortogram - normal system. No aneurysm. No
dissection. No significant aortic insufficiency seen.
7. Right iliofemoral angiogram - normal visualized system. Minimal
atherosclerosis. Sheath enters at an appropriate level. An
Angio-Seal closure device was placed achieving hemostasis.

ASSESSMENT:
1. Essentially normal intracardiac pressures.
2. Coronary artery disease with borderline stenosis in the proximal
to mid left anterior descending (LAD).
3. No significant valvular abnormalities seen.




Can someone please give me an insight on how to code this report .

thx

I would code 93460 and 93567.
I would not code for the ileofemoral angiography. That was performed to evaluate the access/closure site and should not be separately reported, IMO.

HTH :)
 

jonyleo20

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I'm very confuse about these two CPT Codes 93457, and 93461. Can someone please clearify that for me. I have the Opt Report just incase you want to read it.

Thanks in advance.
 

Jim Pawloski

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I'm very confuse about these two CPT Codes 93457, and 93461. Can someone please clearify that for me. I have the Opt Report just incase you want to read it.

Thanks in advance.
93457 is for Coronary Angiography with bypass grafts, and right heart cath. 93461 is for left and right heart cath with coronaries and bypass grafts. So the only difference is did a catheter go into the left ventricle and pressures reported. If not 93357, if the catheter did go into the LV then 36461.

HTH,
Jim Pawloski, CIRCC
 
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