Okay I am a facility that performs Adult Only of Cardiac Caths. They do not even have congential codes listed on their charge sheets.I am reviewing a case today and I am attaching doctor dictation and F/U Echo report to follow.
Patient scheduled for RHC/LHC Coronary Angiogram. No previous diagnosis of CHD
Patient underwent procedure and was found has a large left to right shunt secondary to an ASD.
RHC Completed and LHC Cath Complete in normal fashion.
Post ECHO done. Thoracic surgeon states this to be a CHD.
Now, do I code this case with CHD Codes or NON-CHD codes since there was no previous CHD diagnosis.
If CHD codes what codes would you use...
Any help would be appreciated....
Here is the long winded doctor dictation for your reading pleasure
PROCEDURES: Right and left heart cardiac catheterization complete with a
right heart cardiac catheterization and included thermodilution, cardiac
outputs, and oxygen saturations in the appropriate locations, and then
there was a big saturation run because of the detection of an
unsuspected left-to-right shunt, and then a heart cardiac
catheterization, which included left ventricular angiography and
selective native coronary angiography.
INDICATIONS: A 77-year-old male with a history of hypertension,
type 2 diabetes mellitus being treated with dietary therapy, and
recently discovered atrial fibrillation, who had an echocardiogram
showing mild to moderate aortic regurgitation, aortic sclerosis without
stenosis, mild mitral regurgitation, mild pulmonary artery systolic
hypertension with moderate tricuspid regurgitation, but initially normal
LV systolic function, who recently was detected to be in atrial
fibrillation in a nuclear stress test performed, during which he had a
limited workload of exercise, developed shortness of breath and fatigue,
had a nuclear scan that showed inferior-apical and apical hypokinesia
and ischemia with a reduced ejection fraction of 48%, who recently
developed the onset of heart failure and was placed on Lasix therapy for
diuresis and was placed on digoxin for atrial fibrillation, was already
on an ACE inhibitor, and prior to placing him on Coumadin, we performed
the right and left heart cardiac catheterization. Now, the patient had
had two prior echocardiograms performed, some of which had disparate
results. One showed normal LV systolic function. The other showed mild
LV systolic dysfunction with an ejection fraction of 51%. The patient
was brought in for right and left heart cardiac catheterization to
evaluate him for pulmonary hypertension given the heart failure, left
heart cardiac catheterization to accurately evaluate LV systolic
function and to evaluate him for significant coronary artery disease
given the positive stress test.
PREOPERATIVE DIAGNOSIS: Possible coronary disease.
POSTOPERATIVE DIAGNOSES
1. Large O2 saturation step-up suggestive of a left-to-right shunt.
2. Pulmonary hypertension.
3. Relatively controlled systemic blood pressure.
4. Cardiac output that was near normal.
5. Concentric left ventricular hypertrophy with normal left ventricular
size and overall normal systolic function.
6. Diffuse coronary disease, including distal left main, left anterior
descending, left circumflex, and right coronary artery disease, and the
disease was felt to be significant.
DESCRIPTION OF PROCEDURE: After the patient had been appropriately
prepped and draped, using a #25-gauge needle and 1% Xylocaine, the skin
overlying the right groin was anesthetized. Next, using a #22-gauge
needle, the subcutaneous tissues down to and surrounding the right
femoral vein and artery were anesthetized. Next, using a #18-gauge
single-wall needle, successful cannulation of the right femoral vein was
obtained. Once free-flowing aspiration of venous material was obtained,
a 0.035 short guidewire was inserted, and over this, a 7-French
intravenous sheath was inserted. The dilator of the sheath was removed.
The sidearm was aspirated and flushed. Next, using a #18-gauge single-
wall needle, successful cannulation of the right femoral artery was
obtained. Once free-flowing return of arterial material was obtained, a
0.035 movable core floppy J guide wire was inserted, and over this, a 6-
French intraarterial sheath was inserted. The dilator of the sheath was
removed. The sidearm was aspirated and flushed. Next, we advanced a
combination of a 6-French pigtail catheter and a 0.035 guidewire into
the right femoral artery and then into the ascending aorta. The
guidewire was removed. The catheter was aspirated and flushed. Next,
aortic pressures were obtained. Next, the pigtail catheter was left in
place while the right heart cardiac catheterization was performed, and
for the right heart cardiac catheterization, we actually eventually
advanced a 7-French thermodilution Swan-Ganz catheter. We did this twice
because of some equipment problems, and the catheter was advanced from
the right femoral vein to the common iliac vein, inferior vena cava,
right atrium, right ventricle, pulmonary artery and pulmonary capillary
wedge pressure positions under both fluoroscopic and hemodynamic
guidance. Then, the pigtail catheter, which was in the aorta, was gently
passed retrograde across the aortic valve, and left ventricular
pressures were obtained. Next, simultaneous left ventricular and
pulmonary capillary wedge pressures were obtained. Next, right heart
pullback was conducted, punctuated by oxygen saturations in the
appropriate locations, but this saturation run demonstrated abnormally
high right atrial and right ventricular saturations. Therefore, a more
thorough oxygen saturation run was performed in this patient by
obtaining a superior vena cava saturation, a high rate atrial
saturation, a mid right atrial saturation, and a right atrial
saturation, and then multiple inferior vena caval saturations, in
addition to systemic saturations. This confirmed a left-to-right shunt,
which I will get into. Once the saturation run had been completed and
the thermodilution cardiac outputs were performed while the Swan-Ganz
catheter was in the pulmonary artery, and this was done several times
because we were getting an abnormal curve from the thermodilution
cardiac outputs and the numbers would not correlate, and then we
actually exchanged out the initial Swan-Ganz catheter for a second 7-
French Swan-Ganz catheter, repeated those numbers, and used another
thermodilution machine, but later we discovered that the patient had a
huge oxygen step-up from left-to-right. Once the cardiac outputs had
been obtained and all of the oxygen saturations had been performed, a
left ventricular angiogram was performed using 25 mL of Omnipaque
contrast agent in the 30-degree RAO view, and we repeated a left
ventricular angiogram using 25 mL of Omnipaque contrast agent in the 30-
degree LAO view just to make sure that the patient did not have a
ventricular septal defect that could be detected angiographically. Once
the left ventricular angiogram had been performed, a careful left heart
pullback was conducted after the catheter was aspirated and flushed, and
then the pigtail catheter was exchanged for #4 Judkins left and #4
Judkins right coronary catheters. Once this procedure was completed, the
catheters were removed from the patient. The intraarterial and
intravenous sheaths were secured in place while we confirmed the
findings of angiography, which demonstrated diffuse coronary disease.
The patient was brought to the post-cath recovery area. He was admitted
to an observation bed on 2-East pending the review of the saturation run
and a repeat echo, which ultimately did show evidence of a large atrial
septal defect with a left-to-right shunt. He tolerated the cardiac
catheterization procedure very well, remaining hemodynamically stable
throughout the procedure. In fact, he was relaxed and slept through most
of the procedure.
HEMODYNAMICS: Mean right atrial pressure 11. Right ventricular pressure
58/1. Pulmonary artery pressure 42/9 with a mean of 22. Pulmonary
capillary wedge pressure was 11. Aortic pressure was 98/45 with a mean
of 65. Left ventricular pressure was 98/4. Post-angiographic contrast
loading, the left ventricular pressure was 118/7, and the aortic
pressure was 122/41 with a mean of 82.
OXYGEN SATURATIONS: This is where it gets very interesting. The
pulmonary capillary wedge saturation was 86%. The pulmonary artery
saturation was 81.5%. The right ventricular saturation was 82.6%, and
then repeated was 82.5%, and then repeated was 82%; we did that 3 times.
The right atrial saturation initially was 78%, then 75.7%, and 81.7%.
Therefore, we did an extensive saturation run in the atrium. He had a
superior vena cava saturation of 53.5%, a high right atrial saturation
of 54.3%, a mid right atrial saturation of 75.4%, a low right atrial
saturation of 78%, and an inferior vena caval saturation of 59.9%, with
a left ventricular saturation of 96.9%, and the average thermodilution
cardiac output was 5.34 L/min for a cardiac index, and then a repeat was
5.03 L/min for a cardiac index of 2.68 L/min per meter squared.
LEFT VENTRICULAR ANGIOGRAPHY: The left ventricular angiogram
demonstrated a left ventricle that was concentrically thickened and
normal in size and overall normal in its systolic function with a left
ventricular ejection fraction measurement of 79%, but there was an LAO
and an RAO left ventricular angiogram. It appeared to be more like 65%.
There was no significant mitral valvular prolapse and mild mitral
regurgitation.
SELECTIVE NATIVE CORONARY ANGIOGRAPHY
LEFT MAIN CORONARY ARTERY: The left main coronary artery was a
calcified, long blood vessel that gave rise to a left anterior
descending and a left circumflex coronary artery. This calcified left
main coronary artery had an ostial 10% stenosis, but the mid body of
this left main coronary artery had an area of lucency probably due to
calcification, and then the distal left main coronary artery had an
eccentric but definite stenosis of about 70% in the distal left main
coronary artery. There was TIMI grade 3 flow down it, however.
LEFT ANTERIOR DESCENDING CORONARY: The left anterior descending coronary
was a large, calcified, long blood vessel that gave rise to several
septal perforators and diagonal branches. The proximal left anterior
descending coronary had an eccentric 60% stenosis. The mid left anterior
descending coronary was diffusely diseased with stenoses of about 70% to
75%, followed by an area of pre-stenotic dilatation, followed by about a
90% stenosis that involved the origin of a diagonal branch. The distal
left anterior descending coronary had no significant stenoses, though
there was mild to moderate plaquing and calcification present. There
were no significant stenoses of the several septal perforators and
diagonal branches, save the mid level diagonal branch, which had its
origin in the 90% stenosis of the left anterior descending coronary
system.
CIRCUMFLEX SYSTEM: The left circumflex system was a moderate-sized
system that was somewhat tortuous, that was calcified, that gave rise to
a high obtuse marginal branch, which was a thin bifurcating vessel, a
distally occurring obtuse marginal branch, which was a larger vessel,
and a posterolateral branch, which bifurcated. The left main circumflex
coronary had tortuosity present with calcification with no significant
stenoses. The high obtuse marginal branch of the left circumflex system
in total, though calcified, had no high-grade stenoses with
calcification and moderate plaquing. The posterolateral portion of the
circumflex system which bifurcated had no significant stenoses. However,
there was a high thin occurring proximal obtuse marginal branch that was
subtotally occluded. There was a second obtuse marginal branch, which
bifurcated. The superior bifurcation was subtotally occluded. The
inferior bifurcation was by far a larger vessel without significant
stenoses.
RIGHT CORONARY ARTERY SYSTEM: The right coronary artery system was a
large, dominant, calcified system that gave rise to a conus artery, a
sinus nodal artery, several right ventricular branches, a posterior
descending, and a posterolateral branch. This large, dominant right
coronary was diffusely calcified. There was mild plaquing in the
proximal right coronary artery, moderate plaquing in the distal right
coronary, and then the distal right coronary artery before giving rise
to a posterolateral branch was 75% to 80% stenosed. The posterolateral
branch itself appeared to have no significant stenoses. However, the
posterior descending branch had about an 85% to 90% ostial stenosis,
followed by an area of pre-stenotic dilatation, followed by another 50%
to 60% stenosis, and this vessel was calcified.
IMPRESSION
1. Mild pulmonary artery systolic hypertension.
2. Normal pulmonary capillary wedge pressure.
3. Large oxygen step-up within the right atrium and right ventricle
suggestive of a left-to-right shunt.
4. Near normal overall cardiac output.
5. Normal pulmonary capillary wedge pressure.
6. Normal systemic blood pressure.
7. Concentric left ventricular hypertrophy with normal left ventricular
size with overall normal systolic function with mitral annular
calcification and mild mitral regurgitation.
8. Diffuse three-vessel system coronary artery disease with the
following:
a. Ostial left main coronary stenosis of 20% with the mid left main
coronary having an eccentric area of calcification with a 50% to 60%
stenosis, and then the distal left main circumflex coronary artery with
about a 70% stenosis.
b. Left anterior descending coronary was diffusely calcified and
diseased with the mid vessel having sequential 75% to 80% and then 90%
stenoses with the second portion of the stenoses involving the origin of
a diagonal branch.
c. Left circumflex system with calcification with a subtotally occluded
small, thin, short obtuse marginal branch, and then a second obtuse
marginal branch to the superior bifurcation was subtotally occluded. The
inferior bifurcation was widely patent. The posterolateral branch was
widely patent, without significant stenoses.
d. Large, dominant right coronary artery, which has diffuse disease
highlighted by a posterior descending branch ostial stenosis of about
85% to 90%.
9. A large left-to-right shunt with a Qp/Qs of 2.67/1. Because of that
large shunt, we obtained a repeat echocardiogram here in the
catheterization lab holding area. The patient has a large atrial septal
defect.
IMPRESSION
1. Pulmonary hypertension.
2. Relatively controlled systemic blood pressure.
3. Near normal cardiac output.
4. Large left-to-right shunt secondary to an atrial septal defect.
5. Three-vessel system coronary artery disease.
6. Concentric left ventricular hypertrophy with normal left ventricular
size and overall normal systolic function with mitral annular
calcification and mild mitral regurgitation, but there is three-vessel
system coronary artery disease, including left main disease.
PLAN: A Cardiothoracic Surgical consultation will be obtained with
respect to the patient having coronary artery bypass graft surgery and
an atrial septal defect repair.
The thoracic surgeon notes in his consult after the cath and then echo was done : "An echocardiogram demonstrated a large left-
right shunt, hence an atrial septal defect that was diagnosed which is
congenital from birth. However, there is no Eisenmenger physiology
noted."