mcauffman86
Networker
How would the following case be coded? I am confused on how the non-selective subclavian angiography would be coded especially??
Procedure Ordered:
Procedure(s):
Right/Left Heart Cath Poss Intervention
Indications:
Dilated cardiomyopathy
Decompensated congestive heart failure
Acute ischemic limb right upper extremity
Occlusion left subclavian artery.
Procedure Performed:
Right heart catheterization, left heart catheterization, coronary artery study
Left internal mammary artery angiography
Nonselective left subclavian artery angiography
Right subclavian artery angiography with runoff
PTCA right proximal brachial artery with a 4.0 mm x 20 mm Balloon and a 5.0 mm x 30 mm Balloon.
Pre-Procedure Diagnosis:
Severity cardiomyopathy with an LV thrombus
Post-Procedure Diagnosis:
Severe multivessel coronary artery disease.
Occlusion left subclavian artery distal to takeoff of the left internal mammary artery.
99% stenosis proximal right brachial artery with TIMI 2 flow
Moderate pulmonary hypertension
Elevated pulmonary capillary wedge pressure
Low cardiac output state
Case Classification:
Add-on (Includes Emergency, NOT trauma)
Stress or Imaging Test Performed:
Transesophageal echocardiogram
Anginal Class:
No symptoms.
Anti-Anginal Meds:
Beta blocker
FluoroTime and Dose:
Radiation Tracking
Event Details User
7:27 PM Radiation Tracking Panel 1: Dale Leffler, DO Total Procedure Dose (uGy-m2) = 7464.000; Air Kerma (mGy) (mGy (milligray)) = 418.000; Fluoro Time (min) = 16.0 ZV
Moderate Sedation:
Moderate sedation was administered using IV Versed and Fentanyl. Patient received continuous EKG, hemodynamic and oximetry monitoring with physician being present for the entire time. Total moderate sedation duration = 65 min.
Estimated Blood Loss:
Minimal
Complications:
No Complications were logged
Procedure Technique:
The risks, benefits, alternatives were explained at length to the patient written informed consent was obtained. The patient's brought to the cardiac catheterization laboratory in the postabsorptive state. Left groin is prepped and draped in usual sterile fashion conscious sedation was administered. 10 mL of 2% lidocaine was used for local limitation utilizing fluoroscopy and ultrasound guidance access was obtained in the right common femoral artery and a 6 French short sheath was placed utilizing the modified salvage technique. Ultrasound was also used to access the right common femoral vein and a 6 French sheath was placed utilizing the modified Seldinger technique. A 5 French balloon tip Swan-Ganz aero catheter was advanced up to the level of the right atrium were sequential pressures were obtained in the right atrium, right ventricle, pulmonary artery a BMW wire was used to advance the Swan-Ganz to the level of the pulmonary A wedge position and waveforms were obtained. Pulmonary artery saturation as well as central arterial. The Swan-Ganz catheter was then removed. A 6 French JL4 was advanced to the left coronary ostium was selective and grams with pain in multiple views. The cath was then exchanged for a 6 French JR4 which was advanced in the right coronary ostium was selective entry grams obtained in multiple views. The catheter was then repositioned at the origin of the left subclavian artery and advanced up to the level of the left internal mammary artery was selective angiography was performed. A nonselective imaging of the left subclavian artery was also performed. The catheter was then repositioned at the origin of the innominate artery and utilizing the stiff angled Glidewire was advanced to the proximal portion of the subclavian artery where angiography was performed. A bursa core wire was placed within the 6 French JR4 catheter down to the level of the proximal brachial artery. The JR4 catheter was then removed. A 6 French shuttle sheath was advanced up to the level of the distal right subclavian artery in the bursa core wire was removed. 4000 units of intravenous heparin was administered. A BMW wire was then placed across the lesion segment involving the proximal right brachial artery. A 4 mm x 20 mm Viatrac balloon was advanced after angiographic confirmation deployed at 8 atm. A second 5 mm x 30 mm Viatrac balloon was advanced and deployed at 8 atm for 60 seconds. Completion angiography demonstrates less than 30% residual stenosis, TIMI-3 flow, no flow-limiting dissections. The catheter was carefully removed over a J-wire. And a 7 French short sheath was placed in the left common femoral artery. The patient tolerated procedure well was transported to the holding area in stable condition.
Contrast:
Medication Name Total Dose
iodixanol (Visipaque) 320 mg/mL injection 118 mL
Hemodynamic Data:
Aortic pressure was: 7/7/2021 7/7/2021 7/7/2021
AO Systolic Pressure 103 142 146
AO Diastolic Pressure 59 97 100
AO Mean Pressure 75 115 105
Hemodynamic data:
Right Atrium: A-wave 16, V-wave 15, mean 13 mmHg
Right ventricle: Peak systolic pressure 52 and diastolic pressure 17 mmHg
Pulmonary artery capillary wedge pressure A-wave 34 V-wave 34 mean of 30 mmHg
Pulmonary artery: 53/27 with a mean of 37 mmHg
Saturations:
Arterial: 99.3%
Pulmonary artery: 61.8%
Calculations:
Fick cardiac output 3.31 L/m
Fick cardiac index 1.72 L/m per body squared surface area
Angiographic Data:
Right coronary artery occluded proximally no significant right to right collaterals.
Left main artery ostial left main 50-60% mid and distal portion of the left main patent bifurcating distally in the left anterior descending left circumflex artery.
Left anterior descending artery with normal course and distribution of the distal aspect reaching and wrapping around the apex of the heart. Long segment of disease proximal portion of the vessel 95% first diagonal branch emanates from the proximal portion left anterior descending artery ostial disease of 90% vessel was small to moderate caliber. Mid left anterior descending artery diffuse disease stenosis of up to 50% distal also demonstrating diffuse disease with stenoses up to 70-80%. Faint left to right collaterals noted.
Left circumflex artery proximal stenosis 90%, small caliber vessel, nondominant, high takeoff first obtuse marginal branch small caliper diffuse disease proximal 70-80 % mid vessel up to 90%. Diffuse disease throughout the midportion circumflex artery with stenosis up to 70% second obtuse marginal branch small to moderate caliper diffuse disease noted throughout the midportion of the vessel with stenosis of 50-60%.
Left ventriculogram not performed known LV thrombus.
Selective left internal mammary artery - angiographically normal.
Nonselective left subclavian artery angiography: Subclavian artery occluded after takeoff of left internal mammary artery and left vertebral artery.
Nonselective right subclavian artery angiography: Right vertebral artery widely patent ostial disease 30% right internal mammary artery widely patent. Right axillary artery widely patent. 95% focal stenosis proximal right brachial artery with TIMI 2 flow distal. Ulnar artery widely patent to the level of the distal ulnar head, radial artery patent but does not opacify distal half of vessel, sluggish flow versus occlusion.
Final Diagnosis:
1. Multivessel coronary artery disease as follows: 95% stenosis proximal LAD, 90% stenosis proximal circumflex artery, occlusion right coronary artery with left-to-right collaterals.
2. Occlusion left subclavian artery after the takeoff of the left internal mammary artery and left vertebral artery.
3. 95% focal stenosis proximal brachial artery
4. Successful PTCA right proximal brachial artery with a 4 mm and 5 mm balloon. No stent placement.
5. Low cardiac output state, cardiac index 1.72 L/m per by squared surface area
6. Moderate pulmonary hypertension - WHO class II
7. Elevated pulmonary capillary wedge pressure
Recommendation:
Patient clinically presented with acute ischemic right upper limb culprit 95% focal stenosis proximal right brachial artery. Continue aspirin and statin. Hold off on Plavix if anticipation of coronary artery bypass grafting. Consultation with CV surgery regarding coronary artery bypass grafting.
Procedure Ordered:
Procedure(s):
Right/Left Heart Cath Poss Intervention
Indications:
Dilated cardiomyopathy
Decompensated congestive heart failure
Acute ischemic limb right upper extremity
Occlusion left subclavian artery.
Procedure Performed:
Right heart catheterization, left heart catheterization, coronary artery study
Left internal mammary artery angiography
Nonselective left subclavian artery angiography
Right subclavian artery angiography with runoff
PTCA right proximal brachial artery with a 4.0 mm x 20 mm Balloon and a 5.0 mm x 30 mm Balloon.
Pre-Procedure Diagnosis:
Severity cardiomyopathy with an LV thrombus
Post-Procedure Diagnosis:
Severe multivessel coronary artery disease.
Occlusion left subclavian artery distal to takeoff of the left internal mammary artery.
99% stenosis proximal right brachial artery with TIMI 2 flow
Moderate pulmonary hypertension
Elevated pulmonary capillary wedge pressure
Low cardiac output state
Case Classification:
Add-on (Includes Emergency, NOT trauma)
Stress or Imaging Test Performed:
Transesophageal echocardiogram
Anginal Class:
No symptoms.
Anti-Anginal Meds:
Beta blocker
FluoroTime and Dose:
Radiation Tracking
Event Details User
7:27 PM Radiation Tracking Panel 1: Dale Leffler, DO Total Procedure Dose (uGy-m2) = 7464.000; Air Kerma (mGy) (mGy (milligray)) = 418.000; Fluoro Time (min) = 16.0 ZV
Moderate Sedation:
Moderate sedation was administered using IV Versed and Fentanyl. Patient received continuous EKG, hemodynamic and oximetry monitoring with physician being present for the entire time. Total moderate sedation duration = 65 min.
Estimated Blood Loss:
Minimal
Complications:
No Complications were logged
Procedure Technique:
The risks, benefits, alternatives were explained at length to the patient written informed consent was obtained. The patient's brought to the cardiac catheterization laboratory in the postabsorptive state. Left groin is prepped and draped in usual sterile fashion conscious sedation was administered. 10 mL of 2% lidocaine was used for local limitation utilizing fluoroscopy and ultrasound guidance access was obtained in the right common femoral artery and a 6 French short sheath was placed utilizing the modified salvage technique. Ultrasound was also used to access the right common femoral vein and a 6 French sheath was placed utilizing the modified Seldinger technique. A 5 French balloon tip Swan-Ganz aero catheter was advanced up to the level of the right atrium were sequential pressures were obtained in the right atrium, right ventricle, pulmonary artery a BMW wire was used to advance the Swan-Ganz to the level of the pulmonary A wedge position and waveforms were obtained. Pulmonary artery saturation as well as central arterial. The Swan-Ganz catheter was then removed. A 6 French JL4 was advanced to the left coronary ostium was selective and grams with pain in multiple views. The cath was then exchanged for a 6 French JR4 which was advanced in the right coronary ostium was selective entry grams obtained in multiple views. The catheter was then repositioned at the origin of the left subclavian artery and advanced up to the level of the left internal mammary artery was selective angiography was performed. A nonselective imaging of the left subclavian artery was also performed. The catheter was then repositioned at the origin of the innominate artery and utilizing the stiff angled Glidewire was advanced to the proximal portion of the subclavian artery where angiography was performed. A bursa core wire was placed within the 6 French JR4 catheter down to the level of the proximal brachial artery. The JR4 catheter was then removed. A 6 French shuttle sheath was advanced up to the level of the distal right subclavian artery in the bursa core wire was removed. 4000 units of intravenous heparin was administered. A BMW wire was then placed across the lesion segment involving the proximal right brachial artery. A 4 mm x 20 mm Viatrac balloon was advanced after angiographic confirmation deployed at 8 atm. A second 5 mm x 30 mm Viatrac balloon was advanced and deployed at 8 atm for 60 seconds. Completion angiography demonstrates less than 30% residual stenosis, TIMI-3 flow, no flow-limiting dissections. The catheter was carefully removed over a J-wire. And a 7 French short sheath was placed in the left common femoral artery. The patient tolerated procedure well was transported to the holding area in stable condition.
Contrast:
Medication Name Total Dose
iodixanol (Visipaque) 320 mg/mL injection 118 mL
Hemodynamic Data:
Aortic pressure was: 7/7/2021 7/7/2021 7/7/2021
AO Systolic Pressure 103 142 146
AO Diastolic Pressure 59 97 100
AO Mean Pressure 75 115 105
Hemodynamic data:
Right Atrium: A-wave 16, V-wave 15, mean 13 mmHg
Right ventricle: Peak systolic pressure 52 and diastolic pressure 17 mmHg
Pulmonary artery capillary wedge pressure A-wave 34 V-wave 34 mean of 30 mmHg
Pulmonary artery: 53/27 with a mean of 37 mmHg
Saturations:
Arterial: 99.3%
Pulmonary artery: 61.8%
Calculations:
Fick cardiac output 3.31 L/m
Fick cardiac index 1.72 L/m per body squared surface area
Angiographic Data:
Right coronary artery occluded proximally no significant right to right collaterals.
Left main artery ostial left main 50-60% mid and distal portion of the left main patent bifurcating distally in the left anterior descending left circumflex artery.
Left anterior descending artery with normal course and distribution of the distal aspect reaching and wrapping around the apex of the heart. Long segment of disease proximal portion of the vessel 95% first diagonal branch emanates from the proximal portion left anterior descending artery ostial disease of 90% vessel was small to moderate caliber. Mid left anterior descending artery diffuse disease stenosis of up to 50% distal also demonstrating diffuse disease with stenoses up to 70-80%. Faint left to right collaterals noted.
Left circumflex artery proximal stenosis 90%, small caliber vessel, nondominant, high takeoff first obtuse marginal branch small caliper diffuse disease proximal 70-80 % mid vessel up to 90%. Diffuse disease throughout the midportion circumflex artery with stenosis up to 70% second obtuse marginal branch small to moderate caliper diffuse disease noted throughout the midportion of the vessel with stenosis of 50-60%.
Left ventriculogram not performed known LV thrombus.
Selective left internal mammary artery - angiographically normal.
Nonselective left subclavian artery angiography: Subclavian artery occluded after takeoff of left internal mammary artery and left vertebral artery.
Nonselective right subclavian artery angiography: Right vertebral artery widely patent ostial disease 30% right internal mammary artery widely patent. Right axillary artery widely patent. 95% focal stenosis proximal right brachial artery with TIMI 2 flow distal. Ulnar artery widely patent to the level of the distal ulnar head, radial artery patent but does not opacify distal half of vessel, sluggish flow versus occlusion.
Final Diagnosis:
1. Multivessel coronary artery disease as follows: 95% stenosis proximal LAD, 90% stenosis proximal circumflex artery, occlusion right coronary artery with left-to-right collaterals.
2. Occlusion left subclavian artery after the takeoff of the left internal mammary artery and left vertebral artery.
3. 95% focal stenosis proximal brachial artery
4. Successful PTCA right proximal brachial artery with a 4 mm and 5 mm balloon. No stent placement.
5. Low cardiac output state, cardiac index 1.72 L/m per by squared surface area
6. Moderate pulmonary hypertension - WHO class II
7. Elevated pulmonary capillary wedge pressure
Recommendation:
Patient clinically presented with acute ischemic right upper limb culprit 95% focal stenosis proximal right brachial artery. Continue aspirin and statin. Hold off on Plavix if anticipation of coronary artery bypass grafting. Consultation with CV surgery regarding coronary artery bypass grafting.