need help billling lhc/stent

bhargavi

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Middletown, DE
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CLINICAL INDICATION
Crescendo angina.

CLINICAL HISTORY
Mary A. Pospichal is a 76 years old woman with a history of coronary artery
disease and distant stenting of the left circumflex artery in April 2006 as
well as hypertension, hyperlipidemia and diabetes. She recently has been
experiencing recurrent exertional chest discomfort. The chest discomfort has
been occurring in a rapidly accelerating pattern such that with minimal
activity she gets recurrent chest discomfort and shortness of breath. This
morning, she actually had two episodes at rest and had an out patient stress
test performed by Dr. Grewal which revealed a large area of ischemia involving
the inferior portion of the apex. She was seen in the office earlier today and
admitted urgently for unstable coronary syndrome. I was asked to perform
urgent coronary angiography on this patient.

TECHNIQUE
After obtaining informed consent, the patient was prepped and draped in the
usual fashion. Approximately 10 milliliters of two percent Lidocaine
anesthesia were administered to the right groin prior to placement of the
arterial sheath. Under fluoroscopic guidance and using the modified Seldinger
technique, a six French arterial sheath was placed without difficulty into the
right femoral artery. We then proceeded with left heart catheterization,
coronary angiography, nonselective injection of the left internal mammary
artery and nonselective injection of the right ileofemoral system utilizing
hand injections of Omnipaque contrast through six French FL4 and FR4 catheters.

FINDINGS
1. Left ventricular pressure was 166/15 millimeters of mercury.
2. Aortic pressure was 166/68 millimeters of mercury.
3. Left main is a large vessel which trifurcates into the left anterior
descending, left circumflex and ramus intermedius branches. In the distal
portion of the left pain, seen only in cranial views is an eccentric 40 to 50
percent stenosis.
4. Left anterior descending is a large vessel which reaches and partially
wraps the coronary apex giving rise to two small to medium size diagonal
branches. The left anterior descending and its branches have no significant
disease of the left anterior descending or its branches. There does appear to
be an intramyocardial segment distally which is not extrinsically compressed
during systole.
5. Left circumflex is a large non dominant vessel which gives rise to a total
of three major obtuse marginal branches. In the osteal portion of the left
circumflex in some views, the stenosis appears to be as severe as 50 percent.
The proximal vessel is free of disease. The first and second obtuse marginal
branches are quite small in caliber and free of disease. The third obtuse
marginal branch is large in caliber. Stents are visualized extending from the
proximal left circumflex, across the first and second obtuse marginal branches,
into the third obtuse marginal branch. This stent is patent. Proximally there
is approximately 20 to 30 percent in stent restenosis noted. In the segment
just beyond the stent, there is an area of tubular focal 40 to 50 percent
disease. The remainder of the obtuse marginal branch is free of disease.
6. The ramus intermedius is a large branching vessel which has proximal 25 to
30 percent disease.
7. Right coronary artery is a large, anatomically dominant vessel which has a
high bifurcation of the posterior descending and posterior lateral branches.
In the osteal to proximal segment, there is a focal 95 percent stenosis. In
the mid vessel there is 80 to 85 percent area of disease. The posterior
descending and posterior lateral branches have minor luminal irregularities.

After reviewing the catheterization films, we felt that the right coronary
artery was by far the most likely culprit for the patient's symptoms. However,
given the questionable degree of stenosis in the distal left main as well as
the osteal left circumflex disease, we felt that an evaluation of the
hemodynamic significance of these lesions needed to be performed in order to
select the most appropriate revascularization strategy. We, therefore, elected
to perform fractional flow reserve calculations on the combination of left main
and left circumflex as well as the left main in isolation across the origin of
the left anterior descending.

The existing six French sheath was maintained in place. Heparin 4000 units by
intravenous bolus was administered in order to achieve an activated clotting
time appropriate for the procedure. The six French FL4 diagnostic catheter was
used for the FFR procedure. This was engaged into the left main. We then
administered 200 micrograms of intracoronary nitroglycerin to allow for maximal
epicardial coronary vasodilatation. We then obtained a 175 centimeters 0.014
inch RADI-Wire and after calibration outside the body, advanced this into the
proximal left main where pressure equalization was performed. We then advanced
the RADI-Wire into the early portion of the left circumflex beyond the lesions
in the distal left main and osteal left circumflex. We then performed FFR
calculations after the administration of 50, 100, and 100 micrograms of
intracoronary adenosine. The minimum FFR across the area of disease in the
distal left main and osteal left circumflex was 0.82 indicating a series of
lesions which though present, were not yet hemodynamically significant. We
then withdrew the RADI-Wire from the left circumflex and advanced it into the
proximal left anterior descending. We performed additional fractional flow
reserve calculations in isolation of the left main utilizing 100 micrograms of
intracoronary adenosine. The minimum FFR across the left main stenosis by
itself was 0.88, again indicating a non hemodynamically significant lesion.
Satisfied with the findings that the left main complex was not hemodynamically
significant, we elected then to proceed with percutaneous intervention of the
right coronary artery.

The FL4 diagnostic catheter was removed. We then obtained a six French JR4
guide catheter with side holes to access the right coronary artery. We then
obtained a 180 centimeters Asahi Prowater straight wire which was advanced with
minimal difficulty into the distal right coronary artery branches. We performed
predilatation first of the mid right coronary artery and then of the osteal to
proximal right coronary artery utilizing a 2.5 by 15 millimeters Emerge balloon
up to as high as 14 atmospheres of pressure. Follow-up angiography after the
administration of 200 micrograms of intracoronary nitroglycerin revealed
improvement in the angiographic caliber and flow within the vessel. We then
proceeded with stenting. We placed in the mid vessel, a 2.5 by 20 millimeters
Promus PREMIER drug eluting stent which was deployed to 18 atmospheres of
pressure. In the osteal to proximal vessel, we placed a 2.75 by 12 millimeters
Promus PREMIER drug eluting stent which was deployed again to 18 atmospheres of
pressure. Follow-up angiography after an additional 200 micrograms of
intracoronary nitroglycerin revealed a good angiographic result with some
diminished stent deployment throughout both stents. We, therefore, performed
post dilatation of both stents. We utilized a 2.75 by 15 millimeters NC Quantum
Apex balloon on the mid vessel stent deployed to as high as 20 atmospheres of
pressure. We then withdrew this balloon and performed post dilatation of the
osteal to proximal right coronary artery stent utilizing a 3.0 by 8 millimeters
NC Quantum balloon to as high as 20 to 22 atmospheres of pressure. Final
angiography after post dilatation revealed an excellent angiographic result
with no significant residual stenosis and no evidence of proximal or distal
edge dissection, thrombosis or spasm. There was TIMI Grade III flow in the
vessel and the patient was asymptomatic. We then concluded the angioplasty
procedure. The coronary guidewires were removed and final angiography revealed
a stable appearance of the right coronary artery. We then concluded the
angiographic procedure as well.

Nonselective injection of the right ileofemoral system performed between the
diagnostic and interventional angiograms, revealed placement of the arterial
sheath in the distal right common femoral artery above the common femoral
bifurcation. However, there was diffuse calcification of the ileofemoral
complex with evidence of 40 percent stenosis at the site of sheath insertion
and multiple 20 and 30 percent areas of disease that superimposed in diffuse
narrowing of the external iliac and common femoral vessel. We, therefore,
elected to utilize manual compression for hemostasis after confirmation of the
activated clotting time which was 185 seconds. The patient was then
transferred to the recovery area in stable condition.

IMPRESSION
1. Severe systemic hypertension with high normal LVEDP.
2. Moderate but non hemodynamically significant left main stenosis.
3. Moderate but non hemodynamically significant osteal left circumflex
disease with patent left circumflex stent.
4. Mild in stent restenosis in left circumflex with moderate in segment
restenosis.
5. Severe right coronary artery disease osteally to proximally and in the mid
vessel status post successful angioplasty and drug eluting stenting times two.
6. Manual compression to be utilized for hemostasis.

PLAN
1. Aspirin for life.
2. Plavix indefinitely.
3. Aggressive risk factor modification.
4. Discharge home tomorrow if hemodynamically stable.

should I bill 93459-xu, 93571,93572,c9600-rc or also add additional c9601-rc?
thanks in advance
 

Jim Pawloski

True Blue
Messages
1,364
Location
Ann Arbor
Best answers
0
CLINICAL INDICATION
Crescendo angina.

CLINICAL HISTORY
Mary A. Pospichal is a 76 years old woman with a history of coronary artery
disease and distant stenting of the left circumflex artery in April 2006 as
well as hypertension, hyperlipidemia and diabetes. She recently has been
experiencing recurrent exertional chest discomfort. The chest discomfort has
been occurring in a rapidly accelerating pattern such that with minimal
activity she gets recurrent chest discomfort and shortness of breath. This
morning, she actually had two episodes at rest and had an out patient stress
test performed by Dr. Grewal which revealed a large area of ischemia involving
the inferior portion of the apex. She was seen in the office earlier today and
admitted urgently for unstable coronary syndrome. I was asked to perform
urgent coronary angiography on this patient.

TECHNIQUE
After obtaining informed consent, the patient was prepped and draped in the
usual fashion. Approximately 10 milliliters of two percent Lidocaine
anesthesia were administered to the right groin prior to placement of the
arterial sheath. Under fluoroscopic guidance and using the modified Seldinger
technique, a six French arterial sheath was placed without difficulty into the
right femoral artery. We then proceeded with left heart catheterization,
coronary angiography, nonselective injection of the left internal mammary
artery and nonselective injection of the right ileofemoral system utilizing
hand injections of Omnipaque contrast through six French FL4 and FR4 catheters.

FINDINGS
1. Left ventricular pressure was 166/15 millimeters of mercury.
2. Aortic pressure was 166/68 millimeters of mercury.
3. Left main is a large vessel which trifurcates into the left anterior
descending, left circumflex and ramus intermedius branches. In the distal
portion of the left pain, seen only in cranial views is an eccentric 40 to 50
percent stenosis.
4. Left anterior descending is a large vessel which reaches and partially
wraps the coronary apex giving rise to two small to medium size diagonal
branches. The left anterior descending and its branches have no significant
disease of the left anterior descending or its branches. There does appear to
be an intramyocardial segment distally which is not extrinsically compressed
during systole.
5. Left circumflex is a large non dominant vessel which gives rise to a total
of three major obtuse marginal branches. In the osteal portion of the left
circumflex in some views, the stenosis appears to be as severe as 50 percent.
The proximal vessel is free of disease. The first and second obtuse marginal
branches are quite small in caliber and free of disease. The third obtuse
marginal branch is large in caliber. Stents are visualized extending from the
proximal left circumflex, across the first and second obtuse marginal branches,
into the third obtuse marginal branch. This stent is patent. Proximally there
is approximately 20 to 30 percent in stent restenosis noted. In the segment
just beyond the stent, there is an area of tubular focal 40 to 50 percent
disease. The remainder of the obtuse marginal branch is free of disease.
6. The ramus intermedius is a large branching vessel which has proximal 25 to
30 percent disease.
7. Right coronary artery is a large, anatomically dominant vessel which has a
high bifurcation of the posterior descending and posterior lateral branches.
In the osteal to proximal segment, there is a focal 95 percent stenosis. In
the mid vessel there is 80 to 85 percent area of disease. The posterior
descending and posterior lateral branches have minor luminal irregularities.

After reviewing the catheterization films, we felt that the right coronary
artery was by far the most likely culprit for the patient's symptoms. However,
given the questionable degree of stenosis in the distal left main as well as
the osteal left circumflex disease, we felt that an evaluation of the
hemodynamic significance of these lesions needed to be performed in order to
select the most appropriate revascularization strategy. We, therefore, elected
to perform fractional flow reserve calculations on the combination of left main
and left circumflex as well as the left main in isolation across the origin of
the left anterior descending.

The existing six French sheath was maintained in place. Heparin 4000 units by
intravenous bolus was administered in order to achieve an activated clotting
time appropriate for the procedure. The six French FL4 diagnostic catheter was
used for the FFR procedure. This was engaged into the left main. We then
administered 200 micrograms of intracoronary nitroglycerin to allow for maximal
epicardial coronary vasodilatation. We then obtained a 175 centimeters 0.014
inch RADI-Wire and after calibration outside the body, advanced this into the
proximal left main where pressure equalization was performed. We then advanced
the RADI-Wire into the early portion of the left circumflex beyond the lesions
in the distal left main and osteal left circumflex. We then performed FFR
calculations after the administration of 50, 100, and 100 micrograms of
intracoronary adenosine. The minimum FFR across the area of disease in the
distal left main and osteal left circumflex was 0.82 indicating a series of
lesions which though present, were not yet hemodynamically significant. We
then withdrew the RADI-Wire from the left circumflex and advanced it into the
proximal left anterior descending. We performed additional fractional flow
reserve calculations in isolation of the left main utilizing 100 micrograms of
intracoronary adenosine. The minimum FFR across the left main stenosis by
itself was 0.88, again indicating a non hemodynamically significant lesion.
Satisfied with the findings that the left main complex was not hemodynamically
significant, we elected then to proceed with percutaneous intervention of the
right coronary artery.

The FL4 diagnostic catheter was removed. We then obtained a six French JR4
guide catheter with side holes to access the right coronary artery. We then
obtained a 180 centimeters Asahi Prowater straight wire which was advanced with
minimal difficulty into the distal right coronary artery branches. We performed
predilatation first of the mid right coronary artery and then of the osteal to
proximal right coronary artery utilizing a 2.5 by 15 millimeters Emerge balloon
up to as high as 14 atmospheres of pressure. Follow-up angiography after the
administration of 200 micrograms of intracoronary nitroglycerin revealed
improvement in the angiographic caliber and flow within the vessel. We then
proceeded with stenting. We placed in the mid vessel, a 2.5 by 20 millimeters
Promus PREMIER drug eluting stent which was deployed to 18 atmospheres of
pressure. In the osteal to proximal vessel, we placed a 2.75 by 12 millimeters
Promus PREMIER drug eluting stent which was deployed again to 18 atmospheres of
pressure. Follow-up angiography after an additional 200 micrograms of
intracoronary nitroglycerin revealed a good angiographic result with some
diminished stent deployment throughout both stents. We, therefore, performed
post dilatation of both stents. We utilized a 2.75 by 15 millimeters NC Quantum
Apex balloon on the mid vessel stent deployed to as high as 20 atmospheres of
pressure. We then withdrew this balloon and performed post dilatation of the
osteal to proximal right coronary artery stent utilizing a 3.0 by 8 millimeters
NC Quantum balloon to as high as 20 to 22 atmospheres of pressure. Final
angiography after post dilatation revealed an excellent angiographic result
with no significant residual stenosis and no evidence of proximal or distal
edge dissection, thrombosis or spasm. There was TIMI Grade III flow in the
vessel and the patient was asymptomatic. We then concluded the angioplasty
procedure. The coronary guidewires were removed and final angiography revealed
a stable appearance of the right coronary artery. We then concluded the
angiographic procedure as well.

Nonselective injection of the right ileofemoral system performed between the
diagnostic and interventional angiograms, revealed placement of the arterial
sheath in the distal right common femoral artery above the common femoral
bifurcation. However, there was diffuse calcification of the ileofemoral
complex with evidence of 40 percent stenosis at the site of sheath insertion
and multiple 20 and 30 percent areas of disease that superimposed in diffuse
narrowing of the external iliac and common femoral vessel. We, therefore,
elected to utilize manual compression for hemostasis after confirmation of the
activated clotting time which was 185 seconds. The patient was then
transferred to the recovery area in stable condition.

IMPRESSION
1. Severe systemic hypertension with high normal LVEDP.
2. Moderate but non hemodynamically significant left main stenosis.
3. Moderate but non hemodynamically significant osteal left circumflex
disease with patent left circumflex stent.
4. Mild in stent restenosis in left circumflex with moderate in segment
restenosis.
5. Severe right coronary artery disease osteally to proximally and in the mid
vessel status post successful angioplasty and drug eluting stenting times two.
6. Manual compression to be utilized for hemostasis.

PLAN
1. Aspirin for life.
2. Plavix indefinitely.
3. Aggressive risk factor modification.
4. Discharge home tomorrow if hemodynamically stable.

should I bill 93459-xu, 93571,93572,c9600-rc or also add additional c9601-rc?
thanks in advance

You are good with your codes, except for the stent. Only charge one stent per vascular family, unless it's a branch of that vessel. So your stent code is C9600-RC.
HTH,
Jim Pawloski, CIRCC
 
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