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LHC with coronary anomaly

  1. #1
    Location
    Phoenix, AZ
    Posts
    620
    Default LHC with coronary anomaly
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    Good morning,

    I'm very new to cath coding and need help deciding if this heart cath may actually be billed as an LHC or a CTA. Please HELP!

    INDICATION FOR PROCEDURE:
    Recurrent chest pain consistent with angina pectoris in a patient with
    multiple risks for coronary artery disease.

    TECHNIQUE:
    After informed consent was obtained from patient, patient was brought to the
    cardiac catheterization laboratory in a fasting nonsedated state. He was
    prepped and draped in sterile manner for the above procedures. Versed and
    fentanyl were used for conscious sedation. 2% Xylocaine was used for
    local anesthesia of the right groin.
    Thereafter, a 6-French sheath was placed in the right femoral artery by
    modified Seldinger technique. A 6-French JL4 catheter was used to
    attempt to engage the left main coronary artery; however, with this
    catheter no evidence of a left main could be found. A 6-French
    multipurpose B2 catheter was then exchanged over a wire. It was found
    that the patient's coronary system is congenitally anomalous. There is a
    common origin for the right coronary artery as well as the left main
    coronary artery. Multiple views of the paient's entire coronary system
    were taken by using th B2 catheter to selectively engage his singular
    coronary ostium. When this was complete the same catheter was used to
    perform the left ventriculogram. The procedure was tolerated well. At
    the conclusion of the procedure, groin hemostasis was achieved with
    direct manual compression.

    Results:
    hemodynamics, no significant gradient across the aortic valve. See
    waveform sheets for details.

    ANGIOGRAPHIC DATA:
    There is a single main origin to the coronary artery tree, which appears
    to arise from the right coronary cusp. The left coronary system begins
    with an extremely long left main coronary artery. It is unclear from
    this study whether this passes between the aorta and pulmonary artery or
    anterior to the aorta; however, the left main itself appears to show mild
    ostial stenosis less than 20%. Due to the catheter engagement, it is
    unclear whether this narrowing is artifact from catheter placement or
    whether it is real. There is no evidence of disease throughout the
    remainder of the left main prior to its division into left anterior
    descending ramus intermedius and left circumflex arteries. The left
    circumflex artery consists only of a high marginal, it is a small
    nondominant vessel. The left anterior descending is a small type 1
    vessel of a single diagonal. There appears to be a mild disease. It
    just shows mild intermittent plaquing, but no hemodynamically significant
    disease. The ramus intermedius is a small vessel with mild-to-moderate
    diffuse disease. Maximal narrowing appears to be 30% to 40%. The right
    coronary artery is a large dominant vessel with no evidence of
    significant disease. There are some minimal irregularities in the distal
    vessels. There is an extensively developed posterolateral artery which
    likely functions at least partially in place of distal circumflex
    marginals, which do not appear to be present. The left ventriculogram
    shows ejection fraction of approximately 55%. No segmental wall motion
    abnormalities. No significant aortic insufficiency or mitral
    regurgitation. The aortic root appears to be normal in size.

    IMPRESSION:
    Congenitally anomalous coronary arteries. There is mild-to-moderate
    plaquing in the ramus intermedius, which appears to be hemodynamically
    insignificant. There are otherwise scattered mild luminal irregularities
    which also appear to be hemodynamically insignificant, and there does
    appear to be a 50% stenosis at the origin of the right coronary artery.
    It is unclear whether this is secondary to catheter-induced spasm given
    the unusual origin of the coronary system. The path of the left main
    coronary artery is also indeterminate from this study.

    RECOMMENDATION:
    CT angiography to determine the course of the left main coronary artery
    as well as to determine whether the possible stenosis at the origin of
    the right coronary artery is indicated. We will attempt to arrange this
    as an outpatient. If there is a significant right coronary stenosis or
    if the left main coronary artery passes posterior to the aorta, surgical
    intervention may be required.

    Thank you so very much for your help!!
    Cyndi Allen, CPC, CIRCC
    2015 Local Chapter President, Casa Grande, AZ

  2. #2
    Default
    Quote Originally Posted by Cyndi113 View Post
    Good morning,

    I'm very new to cath coding and need help deciding if this heart cath may actually be billed as an LHC or a CTA. Please HELP!

    INDICATION FOR PROCEDURE:
    Recurrent chest pain consistent with angina pectoris in a patient with
    multiple risks for coronary artery disease.

    TECHNIQUE:
    After informed consent was obtained from patient, patient was brought to the
    cardiac catheterization laboratory in a fasting nonsedated state. He was
    prepped and draped in sterile manner for the above procedures. Versed and
    fentanyl were used for conscious sedation. 2% Xylocaine was used for
    local anesthesia of the right groin.
    Thereafter, a 6-French sheath was placed in the right femoral artery by
    modified Seldinger technique. A 6-French JL4 catheter was used to
    attempt to engage the left main coronary artery; however, with this
    catheter no evidence of a left main could be found. A 6-French
    multipurpose B2 catheter was then exchanged over a wire. It was found
    that the patient's coronary system is congenitally anomalous. There is a
    common origin for the right coronary artery as well as the left main
    coronary artery. Multiple views of the paient's entire coronary system
    were taken by using th B2 catheter to selectively engage his singular
    coronary ostium. When this was complete the same catheter was used to
    perform the left ventriculogram. The procedure was tolerated well. At
    the conclusion of the procedure, groin hemostasis was achieved with
    direct manual compression.

    Results:
    hemodynamics, no significant gradient across the aortic valve. See
    waveform sheets for details.

    ANGIOGRAPHIC DATA:
    There is a single main origin to the coronary artery tree, which appears
    to arise from the right coronary cusp. The left coronary system begins
    with an extremely long left main coronary artery. It is unclear from
    this study whether this passes between the aorta and pulmonary artery or
    anterior to the aorta; however, the left main itself appears to show mild
    ostial stenosis less than 20%. Due to the catheter engagement, it is
    unclear whether this narrowing is artifact from catheter placement or
    whether it is real. There is no evidence of disease throughout the
    remainder of the left main prior to its division into left anterior
    descending ramus intermedius and left circumflex arteries. The left
    circumflex artery consists only of a high marginal, it is a small
    nondominant vessel. The left anterior descending is a small type 1
    vessel of a single diagonal. There appears to be a mild disease. It
    just shows mild intermittent plaquing, but no hemodynamically significant
    disease. The ramus intermedius is a small vessel with mild-to-moderate
    diffuse disease. Maximal narrowing appears to be 30% to 40%. The right
    coronary artery is a large dominant vessel with no evidence of
    significant disease. There are some minimal irregularities in the distal
    vessels. There is an extensively developed posterolateral artery which
    likely functions at least partially in place of distal circumflex
    marginals, which do not appear to be present. The left ventriculogram
    shows ejection fraction of approximately 55%. No segmental wall motion
    abnormalities. No significant aortic insufficiency or mitral
    regurgitation. The aortic root appears to be normal in size.

    IMPRESSION:
    Congenitally anomalous coronary arteries. There is mild-to-moderate
    plaquing in the ramus intermedius, which appears to be hemodynamically
    insignificant. There are otherwise scattered mild luminal irregularities
    which also appear to be hemodynamically insignificant, and there does
    appear to be a 50% stenosis at the origin of the right coronary artery.
    It is unclear whether this is secondary to catheter-induced spasm given
    the unusual origin of the coronary system. The path of the left main
    coronary artery is also indeterminate from this study.

    RECOMMENDATION:
    CT angiography to determine the course of the left main coronary artery
    as well as to determine whether the possible stenosis at the origin of
    the right coronary artery is indicated. We will attempt to arrange this
    as an outpatient. If there is a significant right coronary stenosis or
    if the left main coronary artery passes posterior to the aorta, surgical
    intervention may be required.

    Thank you so very much for your help!!
    You are billing for a Left Heart Cath.. The CTA is a recommended procedure that the patient may have later.

    Thanks,
    Jim Pawloski CIRCC

  3. #3
    Location
    Phoenix, AZ
    Posts
    620
    Default
    Good morning,

    Thank you, Jim!!
    Cyndi Allen, CPC, CIRCC
    2015 Local Chapter President, Casa Grande, AZ

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