Wiki Svg angiography and lhc, attempted ptca lmca

Jane5711

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PROCEDURE PERFORMED:
1. Left heart cardiac catheterization.
2. Selective coronary artery angiography.
3. Left ventriculography.
4. Attempted percutaneous transluminal coronary angioplasty of the distal
left main coronary artery.

INDICATION:
1. Unstable angina pectoris.
2. Acute coronary artery syndrome.
3. Acute myocardial infarction.
4. 99% stenosis of the distal left main coronary artery and ostial left
circumflex artery with previous history of graft to the left circumflex
artery totally occluded; coronary artery disease with totally occluded
right coronary artery with saphenous vein graft to right coronary artery,
totally occluded proximal left anterior descending artery with LIMA to
LAD.

PROCEDURE IN DETAIL: After the informed consent was obtained, the patient was
prepped and draped in usual sterile fashion, 2% lidocaine was used for local
infiltration in the right groin. Vascular access was obtained in the right
femoral artery, and over a guidewire 6-French arterial sheath was placed in
the right femoral artery.

A 6-French JR4 catheter was introduced over a guidewire selective in the left
coronary artery, and selective left coronary artery angiography was performed.

Over a guidewire, 6-French JR4 catheter was introduced selective in the right
coronary artery and selective right artery angiography was performed.

A 6-French JR4 guide was used to selectively engage the aortocoronary
saphenous graft, and aortic coronary saphenous graft angiography was
performed.

A 6-French XB 3.5 guide without side holes was used to engage the left
coronary artery.

A 0.14 Sion Blue wire was used to try to cross the lesion in the distal left
main coronary artery.

Then this was followed by another attempt with a 0.14 BT Graphix wire. This
was not successful.


Then, a Pilot wire was used to cross the lesion in the distal left main
coronary artery and this was not successful. Balloon support was the added
over the wire, and yet it was not successful, 2+ distal left main coronary
artery.

The patient continued to have chest discomfort.

Repeat emergency consultation with cardiothoracic surgeon was made to see if
he would take the patient to coronary bypass graft surgery.

Dr. ___ reviewed the case thoroughly, he told us that he cannot take
this patient to coronary bypass graft surgery, because she will not survive
the surgery.

After the consultation with him and discussions with the patient, it was
decided to treat this with best medical management we can do for her.

At this point, the guidewire and diagnostic guiding catheters were removed.
Arterial sheath was sutured in place, and patient was transferred in a
critical condition to the ICU for further care on Integrilin drip.

COMPLICATIONS: None.

RESULTS:
1. The left main coronary artery is patent, it divides into left circumflex
artery and a small ramus intermedius artery.
2. Right coronary is totally occluded.
3. The aortocoronary saphenous graft. The aortocoronary saphenous graft is
supplying to the right artery, has a 30% stenosis in its proximal
portion. Mild-to-moderate degenerative disease throughout its course and
distally supplies to the PDA branch of the right coronary artery.
4. The PDA branch of right coronary artery supplies the collaterals of the
left descending artery collateral to the left circumflex artery.
5. Left main coronary artery: Left main coronary artery has a distal 99%
stenosis.
6. Left circumflex artery. Left circumflex artery has an ostial 99%
stenosis. There appears to be presence of large clot in the distal left
main coronary artery.
7. The ramus intermedius artery has 99% stenosis in its proximal portion.
8. The left descending artery is totally occluded in its proximal portion.
9. Left intramammary artery was not engaged, it was noted to be patent by
previous evaluation on 06/09/2017.

LEFT VENTRICULOGRAPHY:
1. Anterobasal normal.
2. Anterolateral some moderate-to-severe hypokinesis.
3. Apical moderate-to-severe hypokinesis.
4. Inferior mid-to-moderate hypokinesis.
5. Posterobasal moderate hypokinesis.
6. Left ventricular ejection fraction is approximately 30% visual estimate
with no significant gradient across the aortic valve noted, 2+ mitral
insufficiency noted.

IMPRESSIONS:


1. Severe critical 99% stenosis of the distal left main coronary artery and
ostial left circumflex artery with a TIMI 2 flow in the left circumflex
artery.
2. Patent saphenous graft to the PDA branch in the right coronary artery
supplying collaterals to the distal LAD and supplying collaterals to the
left circumflex artery distally grade 2 collaterals.
3. The saphenous graft to the left circumflex artery totally occluded.
4. LIMA to LAD, previously noted to be patent.
5. Right coronary totally occluded.
6. Unsuccessful attempt at angioplasty of the distal left main coronary
artery with unable to cross with a wire.

PLAN:
1. The patient will be kept on Integrilin drip.
2. Nitroglycerin drip and morphine.
3. Prognosis is very grave.
4. If the patient does not provide myocardial infarction which is ensuing
related to the distal left main coronary stenosis, then she has a very
poor prognosis overall.
5. Discussed with the patient at this stage when she is ischemic, AICD
implantation is also not a justifiable option, because she will continue
to have significant ischemic arrhythmias in the future for which AICD
will not be of much help.
6. Maximal medical management of ischemic coronary artery disease.
7. Maximal medical management of other medical issues to continue as before.


CODES???

92941 LM 52-REDUCED SERVICE - PROCEDURE WAS ATTEMPTED? - ICD 10 I21.4
93458 26 59
93455 26 59??? aortic coronary SVG angio?
and of course sedation

PLEASE HELP!!!!! I will need to provide proper documentation if "52" is appropriate and want to make sure my coding is correct!!!

Thank you so much to my experienced coders, in advance:)

Jane in distress, once again!
 
This is what I would bill for, I work in a physician office so I don't bill for the sedation that is usually the hospital that does. CPT 93459 includes the graft.

93459-26
92941-52-LM
 
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