Wiki Impella Device

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Can someone please help me? I have coded the following procedure. Is this correct? Physician note below. Insurance has denied the Cardiac cath saying it is bundled with the Impella.
92928-LD
93458-26,XU
92978-26
33990

Question 2 :Also had someone tell me I can not bill for an Impella based on decision from physician that the case is a high risk PCI that wasn't a valid reason for inserting one. Is this true?
Patient troubled by worsening nonexertional chest pain for last couple of months.  Since 3:00 p.m. yesterday he was troubled by intractable chest pain 10/10. EKG showed sinus rhythm with Q-waves in anterior and anterolateral leads with ST elevations.  He came to cath lab for coronary angiogram.  He reports 5/10 chest pain prior to angiogram.

Procedure explained to the patient, with risks and benefits. The patient agreed and signed the consent form.

The patient received a Versed and  fentanyl for conscious sedation. The patient was draped and dressed in the usual sterile fashion. The right wrist  area infiltrated with lidocaine solution. Access to the right femoral artery was successful. Over a wire, 6-French sheath was introduced using modified Seldinger technique.  However wire did not cross radial artery to brachial artery due to 360° arterial loop.  I switched access to right common femoral artery.  Right common femoral artery access was obtained under fluoroscopic guidance.  Six French sheath was introduced into right common femoral artery.

Over the wire, a JR4 diagnostic catheter was used to engage the right coronary artery.  Angiogram performed in LAO, RAO, LAO cranial positions were obtained.  Catheter was exchanged to 6 French CLS 3.5 guide catheter. Multiple pictures with RAO caudal, AP cranial, LAO cranial, shallow RAO, and LAO caudal views were all obtained.  Catheter was exchanged with pigtail and cross the aortic valve into left ventricle.  LV g was performed with 39 mL of contrast.  It showed decreased ejection fraction  To around 30-35% with LVEDP is 18 mmHg.

Coronary angiogram showed around 30% stenosis in RCA.  100% occluded proximal LAD.  20-  30% stenosis in left circumflex, possible occlusion of small OM branch.  TIMI 0 flow present in LAD.  Syntax score is low to intermediate.

Considering massive anterior wall ST-elevation MI, delayed presentation, new onset of acute combined heart failure, and cold to touch, I did proceed with hemodynamic support.  Over the wire 6 French sheath was removed from the right common femoral artery.  A 14 French Impella sheath was placed the right common femoral artery.  A pigtail was used to cross the aortic valve.  Pigtail was exchanged with Impella wire.Impella CP was placed through right groin for hemodynamic support .  Impella was giving 2.7-3 L of cardiac output per minute.  His chest pain started improving.

I accessed 14 French Impella sheath diaphragm with 18 gauge needle at 5 o clock . position.  Six French sheath was introduced into 14 French Impella sheath diaphragm.  Six French 3.5 CLS guide catheter was used to engage left main coronary artery.  Initial attempt with 0.014 in run-through wire to cross the LAD lesion was unsuccessful.  I used 1.25 X 8 mm over-the-wire balloon with 0.014 in whisper wire 300 cm to cross the lesion successfully.  I removed the wire and took distal injection.  It showed intraluminal position of the predilatation balloon.  I exchanged whisper wire with Prowater 0.014 in 300 cm.  Lesion was pre-dilated with 1.25 X 8 mm predilatation balloon.  Is exchanged with 2.5 X 15 mm predilatation balloon to pre dilate the lesion.  Intravascular ultrasound performed to size the lesion, vessel.  A 3 0 X 38 mm drug-eluting stent was placed across the proximal to mid LAD.  Stent was deployed.  Stent was post dilated with 3.5 X 12 mm post dilatation balloon at 15atm for 30 seconds.  Intravascular ultrasound showed proximal stent malposition.  I post dilated proximal mid stent with 4. 0 X 12 mm post dilatation balloon at 15 as for 27 seconds.  Angiogram showed well-expanded stent with no mild apposition and under expansion.  No signs of dissection or hematoma.  Intracoronary nitro and nicardipine was given.  TIMI 2 to 3 flow present in LAD.

After intervention to LAD, I redirected my Prowater wire to OM lesion.  Crossing was unsuccessful.  I used over the wire balloon system with 0.014 in whisper wire to cross the lesion which was unsuccessful.  I decided to manage this lesion with medical therapy in light of radiation limits, small area of distribution, improvement in chest pain and contrast limit.


Guide wire and 6 French sheath was removed through 14 French Impella sheath.  Fourteen French Impella peel-away sheath was removed after externalization, and internal sheath was introduced into right common femoral artery.   Impella position was conformed and secured with 45° angle to the skin.

Plan:

Continue aspirin 81 mg daily and Brilinta 90 mg daily for next 1 year uninterrupted.
Continue high-intensity statin.
Start Lopressor 12.5 mg 2 times a day.
Continue Impella support overnight.
Routine groin care.
Check pulses in right lower extremity.
Check LDH q.6 hours.
Check CBC and BMP q.12 hours
Will continue follow-up.​
Interpretation

-successful PCI to LAD with 1 drug-eluting stent.  Unsuccessful recanalization to small OM branch.
-Continue aspirin 81 mg daily and Brilinta 90 mg daily for next 1 year uninterrupted.
-Continue high-intensity statin.
-Continue Impella support overnight.
-Routine groin care.
-Check pulses in right lower extremity.
-Check LDH q.6 hours.
-Check CBC and BMP q.12 hours
-Will continue follow-up.​
 
Thanks! What are your thoughts on high risk PCI not being a valid reason to code an impella device? I feel this is one of the main reasons my physicians use them.
 
They may think that high risk intervention is on the week side. I think in this case that myocardial infarction w/ heart failure may be a better choice.
 
Have you considered since this was a STEMI, coding 92941 instead of 92928 or is the reason you went with 92928 because the note says delayed presentation?
 
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