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missadeel

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  • 100% subacute thrombosis of distal LAD, moderate, hazy stenosis proximal to occlusion.
  • 90% ostial D1 stenosis.
  • Non-obstructive disease in remainder of vessels.
  • .
  • INTERVENTION:
  • Successful PCI of distal LAD thrombotic occlusion with POBA, Xience Skypoint 3.0 x 18 mm DES to distal LAD stenosis.
  • Successful PCI of Ostial D1 stenosis with Xience Skypoint 2.5 x 15 mm DES.

PROCEDURES PERFORMED:
Coronary angiography
PCI of LAD
PCI of D1

PROCEDURE DETAILS:
The right wrist and and right groin were prepped and draped in a sterile manner.
The soft tissue above the right wrist was locally anesthetized with 1% lidocaine solution.
The right radial artery was accessed with a 20 gauge angiocatheter needle using the through-and-through technique and 5 Fr Glidesheath was placed.

Next, the RCA was engaged with a 5 Fr JR 4 diagnostic catheter and selective angiography was performed in multiple views.
The JR4 was exchanged over a wire for a 5 Fr JL3.5 diagnostic catheter which was used to perform selective angiography of the left coronary system in multiple views.

An EBU 3.5 was then used to engage the LMCA. A Prowater wire was advanced down the LAD to the very distal vessel. Angioplasty was performed with a 2.5 x 12 mm SC balloon with multiple inflations at the distal/apical vessel up to 8 atm. Next, a Xience Skypoint 3.0 x 18 mm DES was deployed to the distal LAD to 12 atm. The stent was post dilated with a 3.0 x 15 mm NC balloon to 15 atm. Next, a Xience 2.5 x 15 mm DES was deployed to the ostial D1 branch to 12 atm. Repeat angiography showed no residual stenosis and TIMI 3 flow.

At the end of the procedure, a equipment was removed and hemostasis was achieved with a radial band.

FINDINGS:
LMCA - Arises from the left sinus of Valsalva, bifurcates into the LAD and LCX. Angiographically patent.

LAD -moderate to large caliber vessel arising from the LMCA. Gives off two moderate-sized diagonal branches and multiple septal perforators. The distal LAD is 100% occluded due to thrombus. Proximal to the occlusion is a 60% irregular stenosis. There is a 90% ostial diagonal one stenosis. The remainder of the LAD has mild nonobstructive disease and areas of ectasia.

LCX -large caliber vessel arising from the LMCA. Gives off a small OM1 and a moderate to large OM two then tapers in the AV groove. The OM two has a superior and inferior branch, the inferior branch has a 60 to 70% mid vessel stenosis. The remainder of the left circumflex has mild nonobstructive disease.

RCA -large caliber vessel arising from the right sinus of Valsalva. Distally gives off moderate to large PDA and a moderate PLB. Proximal RCA has a 40% stenosis. There are diffuse luminal irregularities throughout the RCA and the PDA.


 
  • 100% subacute thrombosis of distal LAD, moderate, hazy stenosis proximal to occlusion.
  • 90% ostial D1 stenosis.
  • Non-obstructive disease in remainder of vessels.
  • .
  • INTERVENTION:
  • Successful PCI of distal LAD thrombotic occlusion with POBA, Xience Skypoint 3.0 x 18 mm DES to distal LAD stenosis.
  • Successful PCI of Ostial D1 stenosis with Xience Skypoint 2.5 x 15 mm DES.

PROCEDURES PERFORMED:
Coronary angiography
PCI of LAD
PCI of D1

PROCEDURE DETAILS:
The right wrist and and right groin were prepped and draped in a sterile manner.
The soft tissue above the right wrist was locally anesthetized with 1% lidocaine solution.
The right radial artery was accessed with a 20 gauge angiocatheter needle using the through-and-through technique and 5 Fr Glidesheath was placed.

Next, the RCA was engaged with a 5 Fr JR 4 diagnostic catheter and selective angiography was performed in multiple views.
The JR4 was exchanged over a wire for a 5 Fr JL3.5 diagnostic catheter which was used to perform selective angiography of the left coronary system in multiple views.

An EBU 3.5 was then used to engage the LMCA. A Prowater wire was advanced down the LAD to the very distal vessel. Angioplasty was performed with a 2.5 x 12 mm SC balloon with multiple inflations at the distal/apical vessel up to 8 atm. Next, a Xience Skypoint 3.0 x 18 mm DES was deployed to the distal LAD to 12 atm. The stent was post dilated with a 3.0 x 15 mm NC balloon to 15 atm. Next, a Xience 2.5 x 15 mm DES was deployed to the ostial D1 branch to 12 atm. Repeat angiography showed no residual stenosis and TIMI 3 flow.

At the end of the procedure, a equipment was removed and hemostasis was achieved with a radial band.

FINDINGS:
LMCA - Arises from the left sinus of Valsalva, bifurcates into the LAD and LCX. Angiographically patent.

LAD -moderate to large caliber vessel arising from the LMCA. Gives off two moderate-sized diagonal branches and multiple septal perforators. The distal LAD is 100% occluded due to thrombus. Proximal to the occlusion is a 60% irregular stenosis. There is a 90% ostial diagonal one stenosis. The remainder of the LAD has mild nonobstructive disease and areas of ectasia.

LCX -large caliber vessel arising from the LMCA. Gives off a small OM1 and a moderate to large OM two then tapers in the AV groove. The OM two has a superior and inferior branch, the inferior branch has a 60 to 70% mid vessel stenosis. The remainder of the left circumflex has mild nonobstructive disease.

RCA -large caliber vessel arising from the right sinus of Valsalva. Distally gives off moderate to large PDA and a moderate PLB. Proximal RCA has a 40% stenosis. There are diffuse luminal irregularities throughout the RCA and the PDA.


Are you coding for physician or hospital? The code set is different?
 
I code for the facility. I don't know if the physician's office can report an angiogram or not.

1. 92943 - modifier "LD", it is for chronic total occlusion stenosis with angioplasty and stent (it is a drug-eluting stent)
2. 92929 -for D1 stent placement
3. 93454 - coronary angiogram (if the patient never had one done recently or patient's health status was changed since recent angiogram, then you can report it with mod 59" or XU ( that is how I report for hospital)

92929 is assigned because D1 is a branch from LD, since a primary CPT code is already assigned for LD, then has to use add-on code for D1.
If LD is not a CTO, the CPT code will be 92928-LD.

Make sure you also assign dx for chronic total occlusion after whatever CAD code you use for this case.
 
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