Lhc w/stent, thrombectomy, multiple ivu's, iabp, impella catheter

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Hello everyone,

I am not sure if my brain is fried from coding today, but this case is stumping me. I would appreciate any help.

Indications for procedure: ST Myocardial Infarction

Sedation was with moderate sedation using Versed and Fetanyl in addition to local anesthesia using 1% Lidocaine.

Procedure note:
Informed consent was obtained prior to performing the procedure. The patient was brought to the cardiac cath suite post absorptive, non sedated state. The right wrist was prepped and draped in usual sterile manner. Lidocaine 1% was used for infiltration anesthesia. Using modified Seldinger technique, a 6 french short sheath was introduced into the right radial artery. Through the sheath, we gave a total of 3000 units of heparin, 300 of nitroglycerin and 2.5mg of verapamil. A JL3.5 6-french diagnostic catheter was advanced over Jwire to the ascending aortic position. The catheter was used to selectively engage the LM. Selective LM angiogram was obtained in multiple orthogonal views. Following that, the catheter was exchanged over Jwire to JR4 6-french guide catheter. The catheter was used to selectively engage the RCA. Selective RC angiogram was obtained in multiple orthogonal views. After reviewing angiographic results, we decided to intervene and investigate the distal LM and ostial LAD and ostial LC stenosis. The catheter was exchanged to EBU 3.5 6-French guide catheter over Jwire. The catheter was used to selectively engage the Left main. Therapeutic doses of heparin were given with documented therapeutic ACTs. The LC was wired using a BMW wire. The LAD was wired using a Prowater wire. This was followed by IVUs of the LAD and Left main. An IVU was done to the LC. Results were showing distal LM less than 6 mm diameter. The ostial LAD was significant in stent re-stenosis and under deployed stent. the ostial LC extending to the distal LM, there was a thrombus with ruptured plaque. Following that, we paged the on call CT surgeon Dr. ___. Discussed the case. However, the patient became unstable with severe chest pain and drop in blood pressure and bradycardia. At that point after discussion with another interventional cardiologist, Dr. ____, the best decision was to proceed with percutaneous intervention.

Right groin access was obtained using modified Seldinger technique and a 6-french short sheath was introduced. Right common femoral artery angiogram was obtained. This was followed by echanging the sheath to 7-French intraaortic ballon pump sheath. An intraaortic balloon pump was placed. Following that, we proceeded with balloon angioplasty of the left circumflex artery using 2.5 x 12 balloon. The patient continued to have chest pain with bradycardia and drop in blood pressure. At this point, left groin access was obtained. A 6-french sheath was introduced. Two Perclose closure devices were deployed in the left common femoral artery. The sheath was reinserted over the heavy impella wire. We dilated the left common femoral artery access with multiple sequential dilators. A 14-french sheath was inserted over the heavy wire. Through the sheath, we advanced a 6-french pigtail catheter. The catheter was used to cross the aortic valve to the left ventricle. LV gram was performed and hand injection of 10mL of contrast. Following that, the catheter was removed over the impella wire. Over the impella wire, the impella catheter was inserted to the left ventricle and connected. Good cardiac output of 2.4 to 2.5 was reported with good augmented pressure. The intraaortic balloon pump was removed. Following that, the patient started to complain of tons of arm pain where his radial access is. So, the right common femoral artery access site was used to complete the intervention. The radial side was removed and TR band was placed to achieve hemostasis. The same EBU catheter 3.5 was used. The LAD and LC were rewired. This was followed by successful deployment of a stent in the ostial LC artery using a 3.0 x 15 mm Xience drug eluting stent. During that process, the LAD wire was removed. Then, it was rewired through the stent struts. The distal LM to the ostial LAD was balloon dilated using a small balloon of 2.0 x 8mm. This was followed by balloon dilation using a 2.5 x 12 mm balloon followed by 3.0 x 12mm balloon. After that, the distal LM to the proximal LAD was stented using a 3.0 x 23mm Xience drug eluting stent. The left circumflex wire was removed during that process. Then, it was rewired after stent deployment. This was followed by post dilation of the left circumflex artery stent using 3.5 x 12mm balloon. The LAD was post dilated with a 3.0 x 12 NC balloon. A kissing balloon angioplasty was performed using high pressure in the LAD followed by high pressure simultanous. Following that, The wires were removed and the balloons were removed. Repeat angiogram showed very good results without complications. The catheter was disengaged and removed outside the body over a Jwire. The IMA catheter was used. The IMA catheter was used to selectively engage the left common iliac artery. A glide advantage wire was used to wire the left external iliac artery. A 7.0 x 20mm pacific over the wire balloon wsa used to do balloon angioplasty in the left external iliac artery. During that process, the impella sheath was removed and the 2 perclose sutures were sutured. Manual pressure was held for 5 minutes while the balloon is inflated. This was satisfactory to achieve hemostasis. Following that, selective left external iliac artery angiogram was obtianed showing no extravasation. The balloon was removed. Angio-seal closure device was used to achieve hemostasis in the right 7 french sheath access. The patient tolderated the procedure well without complications. He was then transported to post catheterization area in stable condition.



Any Help??
 

Jim Pawloski

True Blue
Messages
1,391
Location
Ann Arbor
Best answers
1
Hello everyone,

I am not sure if my brain is fried from coding today, but this case is stumping me. I would appreciate any help.

Indications for procedure: ST Myocardial Infarction

Sedation was with moderate sedation using Versed and Fetanyl in addition to local anesthesia using 1% Lidocaine.

Procedure note:
Informed consent was obtained prior to performing the procedure. The patient was brought to the cardiac cath suite post absorptive, non sedated state. The right wrist was prepped and draped in usual sterile manner. Lidocaine 1% was used for infiltration anesthesia. Using modified Seldinger technique, a 6 french short sheath was introduced into the right radial artery. Through the sheath, we gave a total of 3000 units of heparin, 300 of nitroglycerin and 2.5mg of verapamil. A JL3.5 6-french diagnostic catheter was advanced over Jwire to the ascending aortic position. The catheter was used to selectively engage the LM. Selective LM angiogram was obtained in multiple orthogonal views. Following that, the catheter was exchanged over Jwire to JR4 6-french guide catheter. The catheter was used to selectively engage the RCA. Selective RC angiogram was obtained in multiple orthogonal views. After reviewing angiographic results, we decided to intervene and investigate the distal LM and ostial LAD and ostial LC stenosis. The catheter was exchanged to EBU 3.5 6-French guide catheter over Jwire. The catheter was used to selectively engage the Left main. Therapeutic doses of heparin were given with documented therapeutic ACTs. The LC was wired using a BMW wire. The LAD was wired using a Prowater wire. This was followed by IVUs of the LAD and Left main. An IVU was done to the LC. Results were showing distal LM less than 6 mm diameter. The ostial LAD was significant in stent re-stenosis and under deployed stent. the ostial LC extending to the distal LM, there was a thrombus with ruptured plaque. Following that, we paged the on call CT surgeon Dr. ___. Discussed the case. However, the patient became unstable with severe chest pain and drop in blood pressure and bradycardia. At that point after discussion with another interventional cardiologist, Dr. ____, the best decision was to proceed with percutaneous intervention.

Right groin access was obtained using modified Seldinger technique and a 6-french short sheath was introduced. Right common femoral artery angiogram was obtained. This was followed by echanging the sheath to 7-French intraaortic ballon pump sheath. An intraaortic balloon pump was placed. Following that, we proceeded with balloon angioplasty of the left circumflex artery using 2.5 x 12 balloon. The patient continued to have chest pain with bradycardia and drop in blood pressure. At this point, left groin access was obtained. A 6-french sheath was introduced. Two Perclose closure devices were deployed in the left common femoral artery. The sheath was reinserted over the heavy impella wire. We dilated the left common femoral artery access with multiple sequential dilators. A 14-french sheath was inserted over the heavy wire. Through the sheath, we advanced a 6-french pigtail catheter. The catheter was used to cross the aortic valve to the left ventricle. LV gram was performed and hand injection of 10mL of contrast. Following that, the catheter was removed over the impella wire. Over the impella wire, the impella catheter was inserted to the left ventricle and connected. Good cardiac output of 2.4 to 2.5 was reported with good augmented pressure. The intraaortic balloon pump was removed. Following that, the patient started to complain of tons of arm pain where his radial access is. So, the right common femoral artery access site was used to complete the intervention. The radial side was removed and TR band was placed to achieve hemostasis. The same EBU catheter 3.5 was used. The LAD and LC were rewired. This was followed by successful deployment of a stent in the ostial LC artery using a 3.0 x 15 mm Xience drug eluting stent. During that process, the LAD wire was removed. Then, it was rewired through the stent struts. The distal LM to the ostial LAD was balloon dilated using a small balloon of 2.0 x 8mm. This was followed by balloon dilation using a 2.5 x 12 mm balloon followed by 3.0 x 12mm balloon. After that, the distal LM to the proximal LAD was stented using a 3.0 x 23mm Xience drug eluting stent. The left circumflex wire was removed during that process. Then, it was rewired after stent deployment. This was followed by post dilation of the left circumflex artery stent using 3.5 x 12mm balloon. The LAD was post dilated with a 3.0 x 12 NC balloon. A kissing balloon angioplasty was performed using high pressure in the LAD followed by high pressure simultanous. Following that, The wires were removed and the balloons were removed. Repeat angiogram showed very good results without complications. The catheter was disengaged and removed outside the body over a Jwire. The IMA catheter was used. The IMA catheter was used to selectively engage the left common iliac artery. A glide advantage wire was used to wire the left external iliac artery. A 7.0 x 20mm pacific over the wire balloon wsa used to do balloon angioplasty in the left external iliac artery. During that process, the impella sheath was removed and the 2 perclose sutures were sutured. Manual pressure was held for 5 minutes while the balloon is inflated. This was satisfactory to achieve hemostasis. Following that, selective left external iliac artery angiogram was obtianed showing no extravasation. The balloon was removed. Angio-seal closure device was used to achieve hemostasis in the right 7 french sheath access. The patient tolderated the procedure well without complications. He was then transported to post catheterization area in stable condition.



Any Help??



Hi Carrie,
Good case and this is how I would code:;

93454-XU - Coronary Angio.
92978-LD for LAD IVUS
92979-LC IVUS additional vessel
33967 - for IABP insertion. No code for removal post impella.
33990 - Impella No code for ventriculogram as it is a guiding shot and not mention of findings.
C9600 - LD for hospital, 92928 - LD for physician
C9600 - LC for hospital, 92928-LC for physician

The last part was for closure device for hospital G0269 x 2, physician cannot code for closure device.

HTH,
Jim Pawloski, CIRCC
 
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