I need help with the following procedures, this is the way I coded them and I just need your input.

First procedure

93510 36215-59
93543 75685-2659
93545 92980-RC
93555-2659 92981-LC


Severe obstructive coronary artery disease.

1. Left ventriculogram.
2. Coronary angiogram.
3. Left subclavian angiogram.
4. Left heart catheterization.
5. PTCI of the SVG to the PDA.
6. PTCI x2 of the SVG to the OM 1.
7. PTCA x2 to the proximal and mid circumflex.

IV Versed and fentanyl, with local lidocaine.

See the following heart catheterization report dated November 16,
2009 in regards to dissection and thrombus formation.

The patient was prepped and draped in a sterile manner. A 5-French
23 sheath was placed in the right femoral artery using modified
Seldinger technique. The right femoral artery was heavily calcified
and difficult to cannulate. A JL4 cannulated the left main and
demonstrated 90% proximal circumflex and a 75% mid circumflex lesion.
The LAD was occluded. The diagonal vessels were patent with left to left collaterals.

A JR4 was then utilized to cannulate the right coronary artery which
was occluded within the mid body of the vessel. The JR4 was then
used to cannulate the vein graft, SVG to the ramus was occluded. SVG
to the OM 1 demonstrated a 90% mid body lesion and an 80% distal
anastomosis lesion. Attempts to cannulate the SVG to the PDA were
unsuccessful with the JR4. The JR4 was then utilized to obtain left
subclavian angiogram which demonstrated no significant disease.
Pullback also demonstrated no gradient within the left subclavian
artery. The JR4 was exchanged out for a LIMA catheter which
cannulated the LIMA to the LAD which was patent. Subsequently a
5-French multipurpose cannulated the SVG to the PDA and demonstrated
a 75% mid body lesion within the vein graft portion.

Due to the findings, the patient underwent a multi-vessel
intervention. A multipurpose guide was utilized for the SVG to the
PDA lesion. A BMW 190-cm wire was used across the vessel. A Voyager
2.5 x12 balloon was inflated, leaving a residual 40% lesion.
Subsequently a Promus drug-eluting stent 3.0 x15 was placed in the
mid body of the SVG to the PDA.

Attention was then placed on the SVG to the OM 1. A JR4 guide with a
BMW was utilized. The Voyager 2.5 x12 balloon was placed and inflated
at the distal anastomosis as well as the mid body of the SVG to the
OM 1. Attempts to set the guide at the ostium were difficult and
subsequently the guide was then able to fit and pulled the BMW wire
out of the vessel. Subsequently, a Choice PT was placed back in the
vein graft using the JR4 guide. A Promus 2.75 x28 was placed in the
distal anastomosis. A 2nd Promus 2.75 x28 was placed in the mid body
of the vein graft, with the 2 stents overlapping.

Attention was then placed on the native circumflex. An XB 3.5 guide
and a Choice PT wire were used to cannulate the left main tree and
the circumflex. The 2.5 x 12 Voyager was not utilized. However a 2.5
x12 Voyager was utilized for the mid circumflex lesion with a
residual 20% lesion. The proximal circumflex was then dilated, both
with the Voyager as well as an AngioSculpt balloon 2.5 x10. The 90%
proximal circumflex lesion was reduced to 40%. The mid circumflex
lesion was reduced from 75% to 20%. Prior to intervention, the
patient underwent a left ventriculogram using a pigtail. LV-gram
demonstrated normal left ventricular function of 60% with normal wall
motion abnormalities. Pullback demonstrated no gradient.

1. Occluded SVG to the ramus.
2. Patent LIMA to the LAD.
3. Occluded LAD and RCA disease.

4. A 75% mid body lesion in the SVG to the PDA that was
successfully stented with a drug-eluting stent.
5. SVG to the OM with 2 lesions, 90% at mid body and 80% in the
distal anastomosis, both stented with drug-eluting stents.
6. A 90% proximal circumflex and 75% mid circumflex. Both
lesions successfully ballooned.
7. Normal left ventricular function with an EF of 60%.

Please see next dictation regarding dissection and thrombus formation
in the vein graft.


Second procedure done the same day as the first procedure


Acute stent thrombosis.

1. Dissection and thrombosis of the proximal SVG to the OM 1.
2. Distal edge dissection of the mid SVG to the PDA stent.

1. IVUS of the SVG to the OM 1.
2. Coronary angiogram.
3. PTCI x2 to the SVG to the OM 1.
4. Thrombectomy of the SVG to the OM 1.
5. IVUS of the SVG to the PDA.
6. PTCI of the SVG to the PDA.
IV Versed and fentanyl with local lidocaine.


The patient was taken emergently back to the cath lab after
developing transient bradycardia and hypotension with left neck pain
and dizziness. This was felt to be patient's anginal equivalent.
EKG demonstrated profound ST depressions anteriorly. Patient was
subsequently taken back emergently to the cath lab. The prior
7-French 23 cm sheath was exchanged out for a new 7-French 23 cm
sheath. A 6-French JL4 catheter cannulated the left main and
demonstrated patent circumflex with no change in the residual lesions
of the native circumflex. Subsequently a JR4 catheter was placed
into the SVG to the OM 1 and demonstrated a subtotal occlusion in the
proximal body with thrombus.

A JR4 guide and a Pilot 50 wire were then used to cannulate the SVG
to the OM 1. A Driver thrombectomy catheter was able to remove
approximately 75% to 90% of the thrombus. Intracoronary ReoPro was
administered. Subsequently a 2.5 x12 Voyager balloon was used to
dilate the proximal and ostial SVG to the OM 1. An IVUS run
demonstrated hematoma in the walls of the proximal SVG to the OM 1
suggestive of guide catheter-related dissection. A Promus 3.0 x15
stent was placed at the site of the prior clot; however, subsequent
angiograms demonstrated propagation proximally into the ostium of the

vein graft. Subsequently a 2nd Promus 3.0 x12 was placed overlapping
the stent and extending proximally into the ostium. A repeat IVUS
run demonstrated control of the entrance of the of the
dissection/hematoma of the vein graft with no residual thrombus.

Attention was then placed on the prior SVG to the PDA graft. A
multipurpose catheter was then placed and demonstrated a distal edge
dissection with residual 75% stenosis just after the prior Promus 3.0
x15 stent in the mid body. IVUS confirmed this finding and the area
was directly stented with a 3.0 x18 Promus stent.

Of note, both the prior procedure and this procedure involved
low-pressure balloon and stent deployment and not any high-pressure deployment.

1. Dissection with subtotal occlusion of the ostial and
proximal body of the SVG to the OM with thrombus, requiring
thrombectomy and 2 drug-eluting stents.
2. A 75% distal edge dissection of the SVG to the PDA mid body
distal to the prior stent requiring a second stent Promus 3.0 x18.
3. Patent circumflex.

Thank you.

Maritza Q.