Watkins.Jess
Contributor
When TAVR's are done, usually we have 2 cardiologists who do these and then thy ask a 3rd cardiologist to do the intra-op TEE. I am getting denials because the SAME cardiologist doing the Intra-op TEE is also doing the S/P TTE Limited. How are these to be coded??? I am wondering if I am using the right codes!! I have these coded as CARDIOLOGIST C bills 93355-26 for the intra-op TEE also, CARDIOLOGIST C bills 93308-26 and 93325-26 (which has its separate documentation) for the status post Limited TTE after the TAVR. I see 93318 mentioned in other places but not sure when to use that. Here is an example:
PREOPERATIVE DIAGNOSIS: See Postoperative Progress Record.
POSTOPERATIVE DIAGNOSIS: See Postoperative Progress Record.
OPERATIVE PROCEDURE: TAVR.
INDICATION: The patient is a very pleasant 71-year-old man with history of coronary artery bypass graft surgery with history of ascending aortic aneurysm repair in 2009 with a 34 mm Hemashield graft. Type 2 diabetes mellitus, paroxysmal atrial fibrillation and history of PCI in the past. The patient was found to have severe aortic stenosis that met the criteria for percutaneous TAVR. Transfemoral route. The patient was eligible for a 26 mm Sapien 3 Ultra valve. The patient was not a surgical bailout candidate.
PRIMARY OPERATOR: Cardiologist A
ASSISTANT OR SECONDARY OPERATOR: Cardiologist B
DESCRIPTION OF PROCEDURE: After witnessed informed consent was obtained, the patient was brought to the hybrid OR room, placed on the table, prepped and draped in the usual sterile fashion. TEE performed by Cardiologist C. Please refer to his note for details and also please refer to anesthesia note for details about anesthesia and sedation.
The following accesses were obtained using vascular ultrasound guidance and fluoroscopic landmarks. Right common femoral artery 6-French, left common femoral artery 6-French, left common femoral vein is a 6-French sheath. Next, subsequently a 6-French pigtail catheter was placed in the aortic root in the right aortic cusp from the left transfemoral route over a J-wire. Next, on the right side in the right common femoral artery two Perclose's were done in a pre-close fashion. The sheath was upsized to an 8-French sheath through which a pigtail catheter was then advanced and TAVR sheath that is 14-French sheath was advanced into the descending thoracic aorta. Please note that adequate heparin was given. Therapeutic ACTs were maintained. We did not place a femoral vein sheath. The pacing was done through the neck line via anesthesia. The temporary pacemaker balloon tip was floated and placed in the right ventricle before we started the case. Next, subsequently we chose to cross this valve and AL1 and straight wire combination, we were able to advance the catheter into the left ventricle and a Safari wire was advanced over a pigtail catheter. Next, predilatation of this aortic valve was performed with a 20 mm balloon, one inflation was done after rapid ventricular pacing up to 180 beats per minute. Next, subsequently after that we were able to advance a Sapien 3 Ultra valve. A 26 mm S3 Ultra valve was then advanced and using the standard method after pacing up to 180 and then taking a quick angiogram, we were able to deploy it in the appropriate position at nominal pressures. Subsequently, the balloon was deflated, the pacing was discontinued and after this the system was pulled back and removed. The angiogram revealed minimal to no paravalvular leak. This was confirmed on the TEE also. After this, the whole system was removed and then the Perclose's were deployed and adequate hemostasis was achieved. The left femoral artery was closed using 6-French Angio-Seal without complications. Please note that 75 mg of protamine was given. The patient was transferred to the HVU in a stable condition with a neck line in with a temporary pacemaker which would be monitored.
FINAL DIAGNOSIS: Status post successful TAVR via the right transfemoral route utilizing a 26 mm S3 Ultra valve with no complication.
Please note that at completion contralateral angiogram was performed, which revealed good hemostasis without any issues in the iliofemoral system.
PREOPERATIVE DIAGNOSIS: See Postoperative Progress Record.
POSTOPERATIVE DIAGNOSIS: See Postoperative Progress Record.
OPERATIVE PROCEDURE: TAVR.
INDICATION: The patient is a very pleasant 71-year-old man with history of coronary artery bypass graft surgery with history of ascending aortic aneurysm repair in 2009 with a 34 mm Hemashield graft. Type 2 diabetes mellitus, paroxysmal atrial fibrillation and history of PCI in the past. The patient was found to have severe aortic stenosis that met the criteria for percutaneous TAVR. Transfemoral route. The patient was eligible for a 26 mm Sapien 3 Ultra valve. The patient was not a surgical bailout candidate.
PRIMARY OPERATOR: Cardiologist A
ASSISTANT OR SECONDARY OPERATOR: Cardiologist B
DESCRIPTION OF PROCEDURE: After witnessed informed consent was obtained, the patient was brought to the hybrid OR room, placed on the table, prepped and draped in the usual sterile fashion. TEE performed by Cardiologist C. Please refer to his note for details and also please refer to anesthesia note for details about anesthesia and sedation.
The following accesses were obtained using vascular ultrasound guidance and fluoroscopic landmarks. Right common femoral artery 6-French, left common femoral artery 6-French, left common femoral vein is a 6-French sheath. Next, subsequently a 6-French pigtail catheter was placed in the aortic root in the right aortic cusp from the left transfemoral route over a J-wire. Next, on the right side in the right common femoral artery two Perclose's were done in a pre-close fashion. The sheath was upsized to an 8-French sheath through which a pigtail catheter was then advanced and TAVR sheath that is 14-French sheath was advanced into the descending thoracic aorta. Please note that adequate heparin was given. Therapeutic ACTs were maintained. We did not place a femoral vein sheath. The pacing was done through the neck line via anesthesia. The temporary pacemaker balloon tip was floated and placed in the right ventricle before we started the case. Next, subsequently we chose to cross this valve and AL1 and straight wire combination, we were able to advance the catheter into the left ventricle and a Safari wire was advanced over a pigtail catheter. Next, predilatation of this aortic valve was performed with a 20 mm balloon, one inflation was done after rapid ventricular pacing up to 180 beats per minute. Next, subsequently after that we were able to advance a Sapien 3 Ultra valve. A 26 mm S3 Ultra valve was then advanced and using the standard method after pacing up to 180 and then taking a quick angiogram, we were able to deploy it in the appropriate position at nominal pressures. Subsequently, the balloon was deflated, the pacing was discontinued and after this the system was pulled back and removed. The angiogram revealed minimal to no paravalvular leak. This was confirmed on the TEE also. After this, the whole system was removed and then the Perclose's were deployed and adequate hemostasis was achieved. The left femoral artery was closed using 6-French Angio-Seal without complications. Please note that 75 mg of protamine was given. The patient was transferred to the HVU in a stable condition with a neck line in with a temporary pacemaker which would be monitored.
FINAL DIAGNOSIS: Status post successful TAVR via the right transfemoral route utilizing a 26 mm S3 Ultra valve with no complication.
Please note that at completion contralateral angiogram was performed, which revealed good hemostasis without any issues in the iliofemoral system.
