AmandaM.318414
Guest
Hello,
If anyone is willing to look at this report and point me in the right direction, I will be very greatful for any assistance. This is the cardiologist billing but so far the information I'm getting is Interventional Radiology. I have spent some time attempting to figure several of these out, but don't completely understand what the MD means in several areas. Even if anyone can recommend the best way to learn these it will be helpful.
this is how it was coded with 2013 coding, but I need 2014 coding.
37205
36010 x4
75741-26 x2
36005 x2
Patient was placed under general anesthesia. Local anesthesia was achieved in the right groin region with an injection of a 1:1 mixture of lidocaine 1% and bupivicaine 0.25%. TEE performed at the beginning of the case by Dr.XXXX A 7F sheath was placed in the RFV, which was later exchanged for a 12 Fr Introducer to perform Fontan stenting. A 7F sheath was placed in the RIJ under ultrasound guidance. All sheaths were placed percutaneously via the Seldinger technique. A 6F Wedge and a 5 Fr Pigtail catheter were used to perform a complete right heart catheterization. See above for record of all pressures and saturations measured. A liver biopsy was performed by Dr.XXXXXX. Angiography demonstrated that the previously placed Fontan PG2910B stent had a fracture in it that fractured further s/p liver biopsy, so the decision was made to perform restenting of the fractured stent as described in the 'Interventions' section. Angiography also demonstrated venovenous collaterals arising from the left subclavian vein and venous collaterals arising from the IVC at the level of the hepatic veins, but neither collateral system was coiled as the patient's Glenn and Fontan pressure
throughout was noted to be elevated at 20 mmHg. Initial ACT was 157 and a total of 3000 units of IV
Heparin was administered. Ancef 1g IV was given prior to stent placement. At the end of the case, all
catheters and sheaths were removed and hemostasis was achieved using a perclose device in the RFV and
by manual pressure in the RIJ.
HEMODYNAMICS:
1. Qp:Qs could not accurately be calculated secondary to two sources of pulmonary blood flow.
2. Fontan pressures of 20mmHg. There was no gradient at the IVC-Fontan stent.
3. TPG 9-12 mmHg , RPCW 10 mmHg, LPCW 7 mmHg, PA pressures 19 mmHg, PVRi 3.29 WU indexed
(assuming a pulmonary vein sat of 95%)
INTERVENTIONS:
1. Fontan stent placement: Angiography demonstrated that the previously placed Fontan PG2910B stent
had a fracture that fractured further s/p liver biopsy, so the decision was made to perform restenting of the
fractured stent. The 7 Fr sheath in the RFV was exchanged for a 12 Fr Introducer. A Palmaz P3110 stent
was prepped and loaded onto a 20 mm x 3.5 cm BIB in the usual fashion. The stent apparatus was
advanced into position within the previous stent fracture site. The balloon was inflated and the balloon was
noted to rupture right at the end of inflation. The balloon and delivery system were removed. Follow up
angiography demosntrated no extravsatation of contrast and unobstructed flow through the Fontan circuit
with improved stent caliber.
CINEANGIOGRAMS:
1. Femoral head positioning.
2. Wire in IVC accessed from RFV.
3-4. Wire in LPA accessed from RIJ.
5. Previously placed Fontan stent seen with fracture.
6. Right subclavian vein injection demonstrates unobstructed flow from the right subclavian into the Glenn
with no evidence of collaterals.
7. Glenn injection demonstrates unobstructed flow through the Glenn and into the branch pulmonary
arteries.
8. Left subclavian vein injection demonstrates unobstructed flow from the left subclavian into the Glenn.
There is a large venovenous collateral system arising from the left subclavian vein.
9. LPA injection demonstrates a well-sized LPA with good arborization of the left lung fields and normal leftsided
pulmonary venous return to the left atrium. Good LV function.
10. Distal Glenn/MPA: Injection into the Glenn insertion site demonstrates well-sized bilateral branch PAs
with no obstruction to flow. There is good arborization of bilateral lung fields. On levophase, there is normal
pulmonary venous return bilaterally to the left atrium. On this injection, there appears to be rapid pulmonary
venous return.
11. S/p liver biopsy, the previously placed Fontan stent is seen again with a fracture, but now the fracture
has become more apparent.
12. Injection into the Fontan stent demonstrates unobstruced flow throughout the Fontan circuit. The hepatic
veins are seen filling with this injection. There is no extravsation of contrast.
13. IVC: Injection into the IVC below the takeoff of the hepatic veins and below the Fontan stent
demonstrates unobstructed flow from the IVC into the Fontan. Again, we see the hepatic veins fill along with
the Fontan and there is no extravasation of contrast. There are venous collaterals seen arising from the IVC
at the level of the hepatic veins.
14. Hepatic Veins: Injection into the hepatic veins demonstrates filling of the hepatic venous system without
extravsation of contrast.
15-16. Injection into the Fontan stent demonstrates unobstruced flow throughout the Fontan circuit. The
hepatic veins are seen filling with this injection. There is no extravsation of contrast. There are venous
collaterals seen arising from the IVC at the level of the hepatic veins.
17. Hepatic vein: Injection into the renal veins demonstrates unobstructed flow into the IVC and further into
the Fontan circuit, there is no extravasation of contrast. There are venous collaterals seen arising from the
IVC at the level of the hepatic veins. A fractured portion of the PG 2910 stent is noted in the hepatic vein.
18. Inflation of Palmaz 3110 stent on a 20 mm x 3.5 cm BIB - inflation of the inner balloon.
19. Inflation of Palmaz 3110 stent on a 20 mm x 3.5 cm BIB - inflation of the outer balloon. At the end of
inflation, the balloon is noted to rupture likely by the fractured stent.
20. Good positioning of the Palmaz 3110 stent in the previously placed PG2910B stent.
21. IVC. Post Fontan re-stenting angiography demonstrates no extravasation of contrast. The stent caliber
has improved. There is no obstruction to flow from the IVC into the Fontan circuit. The hepatic veins are also
seen filling. There are venous collaterals seen arising from the IVC at the level of the hepatic veins.
OCCLUDED VESSELS: NONE
COMPLICATIONS: NONE
EBL: 15 mL plus labs
CONCLUSION/DIAGNOSIS:
1. xx yo female with history of DILV and coarctation of the aorta, s/p PA band at 6 months age, s/p resection
of obstructed BVF at 6 years of age, s/p repeat resection of obstructed BVF, aortic valve repair, and Glenn
shunt at 19 years of age, then s/p extracardiac Fontan with oversewing of MPA at age 23 years with residual
elevated right hemidiaphragm. Also with history of mild coarctation of the aorta documented on a 2005 MRI.
History of ITP, ascites s/p paracentesis multiple times, and recent treatment for zoster and pain around her
pacemaker site. In 2013, she was diagnosed with 2:1 block with a HR 30-40 s/p epicardial PPM.
2. CATH 10/28/2010, which demonstrated a discrete narrowing in the IVC/Fontan junction s/p PG2910B
stent inflated to 20 atm on a 18 mm BIB and post-dilated using a 20 mm x 4 cm Z-MED II balloon, and also
s/p embolization of large veno-venous collateral arising from the inominate vein and draining into the heart.
3. Now with recurrent ascites and need for recurrent paracentesis and possible cirrhosis s/p liver biopsy
2/20/14 by Dr. xxxx and s/p assessment of Fontan pressures today by Dr. xxxxx.
4. Fontan filling pressures 20 mmHg, TPG 9-12 mmHg, Wedge 7-10 mmHg, PA pressures 19 mmHg, PVRi
3.29 WU indexed (assuming a pulmonary vein sat of 95%)
5. Venovenous collaterals arising from the left subclavian vein and venous collaterals arising from the IVC at
the level of the hepatic veins, but neither collateral system was coiled as the patient's Glenn and Fontan
pressures throughout were noted to be elevated at 20 mmHg.
6. Inital Fontan PG2910B stent noted to be fractured, which fractured further during liver biopsy, therefore
decision made to perform re-stenting, now s/p Palmaz P3110 stent insertion at the previous Fontan stent
site inflated on a 20 mm x 3.5 cm BIB by Dr. xxxx and Dr. xxxx on 2/20/14.
7. Transjugular liver biopsy performed today by Dr. xxxx, will await pathology results.
DISPO: The patient will receive routine post cath care in the PACU/PTU
If anyone is willing to look at this report and point me in the right direction, I will be very greatful for any assistance. This is the cardiologist billing but so far the information I'm getting is Interventional Radiology. I have spent some time attempting to figure several of these out, but don't completely understand what the MD means in several areas. Even if anyone can recommend the best way to learn these it will be helpful.
this is how it was coded with 2013 coding, but I need 2014 coding.
37205
36010 x4
75741-26 x2
36005 x2
Patient was placed under general anesthesia. Local anesthesia was achieved in the right groin region with an injection of a 1:1 mixture of lidocaine 1% and bupivicaine 0.25%. TEE performed at the beginning of the case by Dr.XXXX A 7F sheath was placed in the RFV, which was later exchanged for a 12 Fr Introducer to perform Fontan stenting. A 7F sheath was placed in the RIJ under ultrasound guidance. All sheaths were placed percutaneously via the Seldinger technique. A 6F Wedge and a 5 Fr Pigtail catheter were used to perform a complete right heart catheterization. See above for record of all pressures and saturations measured. A liver biopsy was performed by Dr.XXXXXX. Angiography demonstrated that the previously placed Fontan PG2910B stent had a fracture in it that fractured further s/p liver biopsy, so the decision was made to perform restenting of the fractured stent as described in the 'Interventions' section. Angiography also demonstrated venovenous collaterals arising from the left subclavian vein and venous collaterals arising from the IVC at the level of the hepatic veins, but neither collateral system was coiled as the patient's Glenn and Fontan pressure
throughout was noted to be elevated at 20 mmHg. Initial ACT was 157 and a total of 3000 units of IV
Heparin was administered. Ancef 1g IV was given prior to stent placement. At the end of the case, all
catheters and sheaths were removed and hemostasis was achieved using a perclose device in the RFV and
by manual pressure in the RIJ.
HEMODYNAMICS:
1. Qp:Qs could not accurately be calculated secondary to two sources of pulmonary blood flow.
2. Fontan pressures of 20mmHg. There was no gradient at the IVC-Fontan stent.
3. TPG 9-12 mmHg , RPCW 10 mmHg, LPCW 7 mmHg, PA pressures 19 mmHg, PVRi 3.29 WU indexed
(assuming a pulmonary vein sat of 95%)
INTERVENTIONS:
1. Fontan stent placement: Angiography demonstrated that the previously placed Fontan PG2910B stent
had a fracture that fractured further s/p liver biopsy, so the decision was made to perform restenting of the
fractured stent. The 7 Fr sheath in the RFV was exchanged for a 12 Fr Introducer. A Palmaz P3110 stent
was prepped and loaded onto a 20 mm x 3.5 cm BIB in the usual fashion. The stent apparatus was
advanced into position within the previous stent fracture site. The balloon was inflated and the balloon was
noted to rupture right at the end of inflation. The balloon and delivery system were removed. Follow up
angiography demosntrated no extravsatation of contrast and unobstructed flow through the Fontan circuit
with improved stent caliber.
CINEANGIOGRAMS:
1. Femoral head positioning.
2. Wire in IVC accessed from RFV.
3-4. Wire in LPA accessed from RIJ.
5. Previously placed Fontan stent seen with fracture.
6. Right subclavian vein injection demonstrates unobstructed flow from the right subclavian into the Glenn
with no evidence of collaterals.
7. Glenn injection demonstrates unobstructed flow through the Glenn and into the branch pulmonary
arteries.
8. Left subclavian vein injection demonstrates unobstructed flow from the left subclavian into the Glenn.
There is a large venovenous collateral system arising from the left subclavian vein.
9. LPA injection demonstrates a well-sized LPA with good arborization of the left lung fields and normal leftsided
pulmonary venous return to the left atrium. Good LV function.
10. Distal Glenn/MPA: Injection into the Glenn insertion site demonstrates well-sized bilateral branch PAs
with no obstruction to flow. There is good arborization of bilateral lung fields. On levophase, there is normal
pulmonary venous return bilaterally to the left atrium. On this injection, there appears to be rapid pulmonary
venous return.
11. S/p liver biopsy, the previously placed Fontan stent is seen again with a fracture, but now the fracture
has become more apparent.
12. Injection into the Fontan stent demonstrates unobstruced flow throughout the Fontan circuit. The hepatic
veins are seen filling with this injection. There is no extravsation of contrast.
13. IVC: Injection into the IVC below the takeoff of the hepatic veins and below the Fontan stent
demonstrates unobstructed flow from the IVC into the Fontan. Again, we see the hepatic veins fill along with
the Fontan and there is no extravasation of contrast. There are venous collaterals seen arising from the IVC
at the level of the hepatic veins.
14. Hepatic Veins: Injection into the hepatic veins demonstrates filling of the hepatic venous system without
extravsation of contrast.
15-16. Injection into the Fontan stent demonstrates unobstruced flow throughout the Fontan circuit. The
hepatic veins are seen filling with this injection. There is no extravsation of contrast. There are venous
collaterals seen arising from the IVC at the level of the hepatic veins.
17. Hepatic vein: Injection into the renal veins demonstrates unobstructed flow into the IVC and further into
the Fontan circuit, there is no extravasation of contrast. There are venous collaterals seen arising from the
IVC at the level of the hepatic veins. A fractured portion of the PG 2910 stent is noted in the hepatic vein.
18. Inflation of Palmaz 3110 stent on a 20 mm x 3.5 cm BIB - inflation of the inner balloon.
19. Inflation of Palmaz 3110 stent on a 20 mm x 3.5 cm BIB - inflation of the outer balloon. At the end of
inflation, the balloon is noted to rupture likely by the fractured stent.
20. Good positioning of the Palmaz 3110 stent in the previously placed PG2910B stent.
21. IVC. Post Fontan re-stenting angiography demonstrates no extravasation of contrast. The stent caliber
has improved. There is no obstruction to flow from the IVC into the Fontan circuit. The hepatic veins are also
seen filling. There are venous collaterals seen arising from the IVC at the level of the hepatic veins.
OCCLUDED VESSELS: NONE
COMPLICATIONS: NONE
EBL: 15 mL plus labs
CONCLUSION/DIAGNOSIS:
1. xx yo female with history of DILV and coarctation of the aorta, s/p PA band at 6 months age, s/p resection
of obstructed BVF at 6 years of age, s/p repeat resection of obstructed BVF, aortic valve repair, and Glenn
shunt at 19 years of age, then s/p extracardiac Fontan with oversewing of MPA at age 23 years with residual
elevated right hemidiaphragm. Also with history of mild coarctation of the aorta documented on a 2005 MRI.
History of ITP, ascites s/p paracentesis multiple times, and recent treatment for zoster and pain around her
pacemaker site. In 2013, she was diagnosed with 2:1 block with a HR 30-40 s/p epicardial PPM.
2. CATH 10/28/2010, which demonstrated a discrete narrowing in the IVC/Fontan junction s/p PG2910B
stent inflated to 20 atm on a 18 mm BIB and post-dilated using a 20 mm x 4 cm Z-MED II balloon, and also
s/p embolization of large veno-venous collateral arising from the inominate vein and draining into the heart.
3. Now with recurrent ascites and need for recurrent paracentesis and possible cirrhosis s/p liver biopsy
2/20/14 by Dr. xxxx and s/p assessment of Fontan pressures today by Dr. xxxxx.
4. Fontan filling pressures 20 mmHg, TPG 9-12 mmHg, Wedge 7-10 mmHg, PA pressures 19 mmHg, PVRi
3.29 WU indexed (assuming a pulmonary vein sat of 95%)
5. Venovenous collaterals arising from the left subclavian vein and venous collaterals arising from the IVC at
the level of the hepatic veins, but neither collateral system was coiled as the patient's Glenn and Fontan
pressures throughout were noted to be elevated at 20 mmHg.
6. Inital Fontan PG2910B stent noted to be fractured, which fractured further during liver biopsy, therefore
decision made to perform re-stenting, now s/p Palmaz P3110 stent insertion at the previous Fontan stent
site inflated on a 20 mm x 3.5 cm BIB by Dr. xxxx and Dr. xxxx on 2/20/14.
7. Transjugular liver biopsy performed today by Dr. xxxx, will await pathology results.
DISPO: The patient will receive routine post cath care in the PACU/PTU