bennieyoung
Guru
I coded this as :
93458 - 26,59 diagnosis codes: I21.4, I25.10
92941 - LD diagnosis codes: I21.4, I25.10
92978 - 26 diagnosis codes: I21.4, I25.10
This is being denied CO-50. I'm not seeing what I'm doing wrong. Can I get some thoughts from some of you as to how you would have coded it?
PROCEDURE: Left heart catheterization, coronary angiography, percutaneous coronary intervention, drug-eluting stent placement x1 to the mid LAD, intravascular ultrasound, conscious sedation.
INDICATION: He is a 56-year-old man who has generally been very healthy. He had acute onset of severe shortness of breath and fatigue while running. These symptoms persisted for hours. He presented to the emergency room with ongoing symptoms. He had subtle ST segment changes on his ECG which did not meet criteria for ST-elevation MI. However, given his ongoing symptoms and the concern that there could be a cardiovascular cause for his acute presentation, he was brought urgently to the cardiac catheterization lab for further risk stratification.
DESCRIPTION OF PROCEDURE: Risks and benefits were discussed including but not limited to infection, bleeding, stroke, vascular injury, arrhythmia, kidney injury, and death. Verbal informed consent was obtained.
1. The patient was brought to the cardiac catheterization laboratory, where he was prepped and draped in the usual sterile fashion.
2. 1% Lidocaine was used for local anesthesia.
3. Fentanyl and Versed were used for procedural sedation.
4. A micropuncture needle was used to gain access in the right radial artery. A 6F Terumo slender glidesheath (10cm) was inserted into this artery using the modified Seldinger technique. Verapamil was administered intra-arterially to prevent spasm.
5. Equipment used for diagnostic procedure: 5F Jacky Radial 3.5.
6. An 0.035" Standard J 260 cm was used to obtain access to the ascending aorta through the right subclavian and was used for catheter exchanges.
7. Weight-adjusted Heparin was used for anticoagulation.
8. The left main coronary ostium was selectively engaged with the Jacky catheter and angiograms were taken in multiple projections. The right coronary ostium was selectively engaged with the Jacky catheter and angiograms were taken in multiple projections.
9. The Jacky catheter was introduced in a retrograde fashion across the aortic valve into the LV and pressure measurements were made.
10. At the end of the case, the sheath was removed and a TR band was applied to the site.
11. There were no apparent complications and the patient was transferred to the ICU in stable condition.
MODERATE SEDATION:
This procedure was performed under moderate sedation using fentanyl and versed. Prior to the procedure, the patient was deemed an appropriate candidate for moderate sedation as documented in the chart. For full documentation of the pre-sedation and post-sedation assessments and exams as well as full documentation of the administered medications, monitoring, and patient response to moderate sedation, please refer to the cardiac catheterization lab nursing flow sheet. This includes a review of the patient's medications, allergies, intolerances, vital signs, pre sedation diagnostic testing, ASA score, and the initiation of IV access. Following the procedure, nursing records from the ACS area and/or the floor accepting the patient after the procedure document the patient's vitals, level of consciousness, and stability from the perspective of neurological, cardiovascular, and pulmonary status after sedation. These also document the patient's readiness for discharge following sedation.
RESULTS:
Hemodynamics
1. Opening Aortic pressure was 110/75.
2. The Left Ventricular pressure was 97/5 with an LVEDP of 8 mmHg.
3. There was no apparent gradient across the aortic valve upon pullback.
Selective Coronary Angiography:
Left Coronary System:
LEFT MAIN CORONARY: The left main coronary artery was angiographically normal (0% stenosis), and bifurcates into the LAD and LCx.
LEFT ANTERIOR DESCENDING CORONARY ARTERY: The left anterior descending coronary is a large vessel that wraps around the apex. The proximal LAD is a short segment which has a minimal 15% stenosis. The mid LAD has a moderate 40-50% stenosis which appeared hazy in some of the views. There is borderline TIMI 2 flow down the LAD. The distal LAD is angiographically free of significant disease. The 1st diagonal branch is a large vessel which is angiographically free of significant disease.
LEFT CIRCUMFLEX CORONARY ARTERY: The left circumflex coronary artery is a large vessel that is nondominant. The left circumflex, OM branches, and distal L PL branches are angiographically free of significant disease with TIMI 3 flow.
Right Coronary System:
RIGHT CORONARY ARTERY: The right coronary artery is a large, dominant vessel. The proximal RCA has mild luminal irregularities. The mid and distal RCA are angiographically free of significant disease. The RCA then gives off an intermediate sized RPDA and a large set of RPL branches which are angiographically free of significant disease with TIMI 3 flow.
Intervention to the mid LAD:
A 6F EBU 3.5 guiding catheter was used to cannulate the ostium of the left main coronary artery after a therapeutic ACT was obtained. A short run-through wire was passed distal to lesion in the mid LAD without difficulty. Intravascular ultrasound was performed. This demonstrated atherosclerotic plaque in the mid LAD. It appeared moderate in severity, but some of the passes over the lesion seem to demonstrate possible ulceration with possible thrombus formation on the lesion. This seemed concerning for an acute coronary syndrome with an active ulcerated lesion. This correlated with a hazy appearance on angiography with borderline TIMI 2 flow down the LAD. As such, decision was made to intervene upon the mid LAD, as this was supplying a large territory of myocardium. A short Prowater wire was advanced into the 1st diagonal branch to protect this vessel. A 3.5 x 12 mm Boston scientific Synergy XD stent was positioned angiographically overlying lesion. The stent was deployed to high pressures. The stent balloon was deflated was reinflated to high pressures. Test angiography demonstrated excellent stent apposition and flow down the diagonal branch. An attempt was made to advance a 4 x 8 mm NC emerge balloon, but this would not cross into the stented segment. A short intuition wire was advanced into the 1st diagonal branch. The Prowater wire was withdrawn. The 4 x 8 mm NC emerge balloon was advanced into the proximal portion of the stented segment. The balloon was inflated to high pressures. Angiography demonstrated excellent stent apposition and expansion. Final intravascular ultrasound was performed. This demonstrated excellent stent apposition and expansion without evidence of edge dissection or plaque prolapse. There was 0% residual stenosis noted on final angiography. There was TIMI 3 flow down the LAD at the end of the case. The patient tolerated the procedure well and states that the shortness of breath that he was having resolved with intervention to the LAD. The patient was loaded with Brilinta 180 mg while on the table.
COMPLICATIONS:
None
Estimated Blood Loss:
Minimal
DIAGNOSTIC IMPRESSIONS:
1. Acute non ST-elevation myocardial infarction status post successful drug-eluting stent placement x1 to the mid LAD.
2. Minimal coronary artery disease otherwise.
3. Normal LV filling pressures with LVEDP of 8 mmHg.
PLAN:
1. Aspirin 81 mg daily indefinitely.
2. Brilinta 90 mg twice daily. This may be transitioned to Plavix if needed based on cost.
3. Initiate rosuvastatin 20 mg daily. Check lipids.
4. Initiate a normal saline drip given his acute kidney injury. Monitor renal function closely. Will defer to Hospital Medicine to help workup his acute renal failure.
5. We will check an echocardiogram tomorrow and make recommendations with regards to the need for afterload reducing agents based on the findings.
6. Given his high-risk NSTEMI, we will monitor the patient in the Intensive Care Unit overnight. We will transition to the telemetry floor tomorrow.
93458 - 26,59 diagnosis codes: I21.4, I25.10
92941 - LD diagnosis codes: I21.4, I25.10
92978 - 26 diagnosis codes: I21.4, I25.10
This is being denied CO-50. I'm not seeing what I'm doing wrong. Can I get some thoughts from some of you as to how you would have coded it?
PROCEDURE: Left heart catheterization, coronary angiography, percutaneous coronary intervention, drug-eluting stent placement x1 to the mid LAD, intravascular ultrasound, conscious sedation.
INDICATION: He is a 56-year-old man who has generally been very healthy. He had acute onset of severe shortness of breath and fatigue while running. These symptoms persisted for hours. He presented to the emergency room with ongoing symptoms. He had subtle ST segment changes on his ECG which did not meet criteria for ST-elevation MI. However, given his ongoing symptoms and the concern that there could be a cardiovascular cause for his acute presentation, he was brought urgently to the cardiac catheterization lab for further risk stratification.
DESCRIPTION OF PROCEDURE: Risks and benefits were discussed including but not limited to infection, bleeding, stroke, vascular injury, arrhythmia, kidney injury, and death. Verbal informed consent was obtained.
1. The patient was brought to the cardiac catheterization laboratory, where he was prepped and draped in the usual sterile fashion.
2. 1% Lidocaine was used for local anesthesia.
3. Fentanyl and Versed were used for procedural sedation.
4. A micropuncture needle was used to gain access in the right radial artery. A 6F Terumo slender glidesheath (10cm) was inserted into this artery using the modified Seldinger technique. Verapamil was administered intra-arterially to prevent spasm.
5. Equipment used for diagnostic procedure: 5F Jacky Radial 3.5.
6. An 0.035" Standard J 260 cm was used to obtain access to the ascending aorta through the right subclavian and was used for catheter exchanges.
7. Weight-adjusted Heparin was used for anticoagulation.
8. The left main coronary ostium was selectively engaged with the Jacky catheter and angiograms were taken in multiple projections. The right coronary ostium was selectively engaged with the Jacky catheter and angiograms were taken in multiple projections.
9. The Jacky catheter was introduced in a retrograde fashion across the aortic valve into the LV and pressure measurements were made.
10. At the end of the case, the sheath was removed and a TR band was applied to the site.
11. There were no apparent complications and the patient was transferred to the ICU in stable condition.
MODERATE SEDATION:
This procedure was performed under moderate sedation using fentanyl and versed. Prior to the procedure, the patient was deemed an appropriate candidate for moderate sedation as documented in the chart. For full documentation of the pre-sedation and post-sedation assessments and exams as well as full documentation of the administered medications, monitoring, and patient response to moderate sedation, please refer to the cardiac catheterization lab nursing flow sheet. This includes a review of the patient's medications, allergies, intolerances, vital signs, pre sedation diagnostic testing, ASA score, and the initiation of IV access. Following the procedure, nursing records from the ACS area and/or the floor accepting the patient after the procedure document the patient's vitals, level of consciousness, and stability from the perspective of neurological, cardiovascular, and pulmonary status after sedation. These also document the patient's readiness for discharge following sedation.
RESULTS:
Hemodynamics
1. Opening Aortic pressure was 110/75.
2. The Left Ventricular pressure was 97/5 with an LVEDP of 8 mmHg.
3. There was no apparent gradient across the aortic valve upon pullback.
Selective Coronary Angiography:
Left Coronary System:
LEFT MAIN CORONARY: The left main coronary artery was angiographically normal (0% stenosis), and bifurcates into the LAD and LCx.
LEFT ANTERIOR DESCENDING CORONARY ARTERY: The left anterior descending coronary is a large vessel that wraps around the apex. The proximal LAD is a short segment which has a minimal 15% stenosis. The mid LAD has a moderate 40-50% stenosis which appeared hazy in some of the views. There is borderline TIMI 2 flow down the LAD. The distal LAD is angiographically free of significant disease. The 1st diagonal branch is a large vessel which is angiographically free of significant disease.
LEFT CIRCUMFLEX CORONARY ARTERY: The left circumflex coronary artery is a large vessel that is nondominant. The left circumflex, OM branches, and distal L PL branches are angiographically free of significant disease with TIMI 3 flow.
Right Coronary System:
RIGHT CORONARY ARTERY: The right coronary artery is a large, dominant vessel. The proximal RCA has mild luminal irregularities. The mid and distal RCA are angiographically free of significant disease. The RCA then gives off an intermediate sized RPDA and a large set of RPL branches which are angiographically free of significant disease with TIMI 3 flow.
Intervention to the mid LAD:
A 6F EBU 3.5 guiding catheter was used to cannulate the ostium of the left main coronary artery after a therapeutic ACT was obtained. A short run-through wire was passed distal to lesion in the mid LAD without difficulty. Intravascular ultrasound was performed. This demonstrated atherosclerotic plaque in the mid LAD. It appeared moderate in severity, but some of the passes over the lesion seem to demonstrate possible ulceration with possible thrombus formation on the lesion. This seemed concerning for an acute coronary syndrome with an active ulcerated lesion. This correlated with a hazy appearance on angiography with borderline TIMI 2 flow down the LAD. As such, decision was made to intervene upon the mid LAD, as this was supplying a large territory of myocardium. A short Prowater wire was advanced into the 1st diagonal branch to protect this vessel. A 3.5 x 12 mm Boston scientific Synergy XD stent was positioned angiographically overlying lesion. The stent was deployed to high pressures. The stent balloon was deflated was reinflated to high pressures. Test angiography demonstrated excellent stent apposition and flow down the diagonal branch. An attempt was made to advance a 4 x 8 mm NC emerge balloon, but this would not cross into the stented segment. A short intuition wire was advanced into the 1st diagonal branch. The Prowater wire was withdrawn. The 4 x 8 mm NC emerge balloon was advanced into the proximal portion of the stented segment. The balloon was inflated to high pressures. Angiography demonstrated excellent stent apposition and expansion. Final intravascular ultrasound was performed. This demonstrated excellent stent apposition and expansion without evidence of edge dissection or plaque prolapse. There was 0% residual stenosis noted on final angiography. There was TIMI 3 flow down the LAD at the end of the case. The patient tolerated the procedure well and states that the shortness of breath that he was having resolved with intervention to the LAD. The patient was loaded with Brilinta 180 mg while on the table.
COMPLICATIONS:
None
Estimated Blood Loss:
Minimal
DIAGNOSTIC IMPRESSIONS:
1. Acute non ST-elevation myocardial infarction status post successful drug-eluting stent placement x1 to the mid LAD.
2. Minimal coronary artery disease otherwise.
3. Normal LV filling pressures with LVEDP of 8 mmHg.
PLAN:
1. Aspirin 81 mg daily indefinitely.
2. Brilinta 90 mg twice daily. This may be transitioned to Plavix if needed based on cost.
3. Initiate rosuvastatin 20 mg daily. Check lipids.
4. Initiate a normal saline drip given his acute kidney injury. Monitor renal function closely. Will defer to Hospital Medicine to help workup his acute renal failure.
5. We will check an echocardiogram tomorrow and make recommendations with regards to the need for afterload reducing agents based on the findings.
6. Given his high-risk NSTEMI, we will monitor the patient in the Intensive Care Unit overnight. We will transition to the telemetry floor tomorrow.
