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Wiki LHC, IABP, and Carotid Angiogram

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willnat2

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Port Charlotte, FL
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I could really use some help with this. We have a new physician and he is doing Carotid Angiograms.

Cath Procedure
Pre-procedure diagnosis:
Resuscitated cardiac arrest.
Non ST-elevation Myocardial infarction.
Post-Procedure diagnosis:
Severe coronary artery disease with 80% left main stenosis, 90% LAD stenosis.
Preserved LV systolic function, EF65%.
Severe right carotid artery stenosis, normal left carotid artery.
Good size LIMA.
Resucitated cardiac arrest, with unknown extent of brain injury.
Procedure performed: diag coronary angiography, left heart cath, left ventrculogram, Bilateral selective carotid angiogram. LIMA angiogram. Placement of intra-aortic balloon pump.

Procedure details:
Vascular access obtained via right femoral artery with micropuncture technique 6 French sheath placed.
Six French pigtail, JR and JL catheters used for left heart catheterization in diagnostic angiogram.
JR4 6 French catheter used for selective carotid angiogram and LIMA angiogram.
Six French sheath exchanged for the 7 French balloon pump sheath.
Balloon pump 50 cc advanced on the floor control to the descending aorta with the tip at the left main bronchus and counterpulsation with one-to-one effectively.

Findings:
Hemodynamics:
Opening the arterial pressure 150/80 mm HG.
Left ventricular pressure 150/5/20 mm Hg with LVEDP of 20 mm Hg.
There was no LV to aorta gradient.
With counterpulsation with intra-aortic balloon pump at one-tone the mean arterial pressure 90 mm Hg.

Left Ventriculogram:
Left ventricle appears of normal size with overall preserved LV ejection fraction of 60-65%.
Angiogram was obtained with the pigtail catheter positioned to the mid LV in RAO projection and manual injection of 10 cc of contrast.

Selective Coronary Angiogram:
Right dominant circulation.
Left main is large vessel which has long ostial proximal 80% stenosis.
LAD is a medium-sized vessel, proximal LAD has luminal irregularities but no significant stenosis: it gives large branching 1st diagonal branch which has proximal 70% stenosis, beyond the bifurcation with the diagonal the mid LAD has long 90% stenosis.
Circumflex is relatively small nondominant vessel OM 1 has 80% stenosis of M@ free of significant disease.
Large dominant right coronary artery has moderate luminal irregularity but no significant stenosis.

Selective Carotid Angiogram:
In expectation of urgent/emergent bypass surgery carotid angiogram was obtained.
Both: Right and then left common carotid artery were cannulated with 6 French JR4 catheter.

Right common carotid artery is large vessel without any significant stenosis the right external carotid arteries patent, the right internal carotid artery has severe 90% proximal stenosis.

Left common carotid artery is a large vessel without any significant stenosis, left internal carotid artery is a large vessel without evidence of stenosis, left external carotid artery is patent.

LIMA is a medium-sized vessel suitable for bypass.


I am not sure what to code for this:

93459
33967
36223-50 or 36222-50

Any help would be greatly appreciated.

Thank you
 
willnat2 said:
I could really use some help with this. We have a new physician and he is doing Carotid Angiograms.

Cath Procedure
Pre-procedure diagnosis:
Resuscitated cardiac arrest.
Non ST-elevation Myocardial infarction.
Post-Procedure diagnosis:
Severe coronary artery disease with 80% left main stenosis, 90% LAD stenosis.
Preserved LV systolic function, EF65%.
Severe right carotid artery stenosis, normal left carotid artery.
Good size LIMA.
Resucitated cardiac arrest, with unknown extent of brain injury.
Procedure performed: diag coronary angiography, left heart cath, left ventrculogram, Bilateral selective carotid angiogram. LIMA angiogram. Placement of intra-aortic balloon pump.

Procedure details:
Vascular access obtained via right femoral artery with micropuncture technique 6 French sheath placed.
Six French pigtail, JR and JL catheters used for left heart catheterization in diagnostic angiogram.
JR4 6 French catheter used for selective carotid angiogram and LIMA angiogram.
Six French sheath exchanged for the 7 French balloon pump sheath.
Balloon pump 50 cc advanced on the floor control to the descending aorta with the tip at the left main bronchus and counterpulsation with one-to-one effectively.

Findings:
Hemodynamics:
Opening the arterial pressure 150/80 mm HG.
Left ventricular pressure 150/5/20 mm Hg with LVEDP of 20 mm Hg.
There was no LV to aorta gradient.
With counterpulsation with intra-aortic balloon pump at one-tone the mean arterial pressure 90 mm Hg.

Left Ventriculogram:
Left ventricle appears of normal size with overall preserved LV ejection fraction of 60-65%.
Angiogram was obtained with the pigtail catheter positioned to the mid LV in RAO projection and manual injection of 10 cc of contrast.

Selective Coronary Angiogram:
Right dominant circulation.
Left main is large vessel which has long ostial proximal 80% stenosis.
LAD is a medium-sized vessel, proximal LAD has luminal irregularities but no significant stenosis: it gives large branching 1st diagonal branch which has proximal 70% stenosis, beyond the bifurcation with the diagonal the mid LAD has long 90% stenosis.
Circumflex is relatively small nondominant vessel OM 1 has 80% stenosis of M@ free of significant disease.
Large dominant right coronary artery has moderate luminal irregularity but no significant stenosis.

Selective Carotid Angiogram:
In expectation of urgent/emergent bypass surgery carotid angiogram was obtained.
Both: Right and then left common carotid artery were cannulated with 6 French JR4 catheter.

Right common carotid artery is large vessel without any significant stenosis the right external carotid arteries patent, the right internal carotid artery has severe 90% proximal stenosis.

Left common carotid artery is a large vessel without any significant stenosis, left internal carotid artery is a large vessel without evidence of stenosis, left external carotid artery is patent.

LIMA is a medium-sized vessel suitable for bypass.


I am not sure what to code for this:

93459
33967
36223-50 or 36222-50

Any help would be greatly appreciated.

Thank you
Click to expand...

You are good with the heart code, and for the carotids I would bill 36223-50
Thanks,
Jim Pawloski,CIRCC
 
Thank you so much. Is it the 36223-50 because both the internal and external carotids were looked at? I just want to make sure that I understand this.
 
willnat2 said:
Thank you so much. Is it the 36223-50 because both the internal and external carotids were looked at? I just want to make sure that I understand this.
Click to expand...

Sorry, my error. I saw the comment of the the internal carotid open, and assumed that the entire cerebral artery was imaged. When I looked at it again, the dictation was vague in what was imaged. 36222 is for just looking at the bifurcations, and 36223 is looking at the internal carotids from a common carotid injection. So I would code 36222 since the anterior and middle cerebral arteries are not mention.

Thanks,
Jim
 
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