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Help coding! R & L Cath with Peripheral procedure

  1. #1
    Location
    Jacksonville Florida
    Posts
    126
    Red face Help coding! R & L Cath with Peripheral procedure
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    Hi everyone! Here's another really long report that I'm stuck on. Any help coding this would be so wonderful




    NAME OF TEST:
    1. Left and right heart cardiac catheterization.
    2. Coronary angiography.
    3. Left ventriculography.
    4. Abdominal aortogram.
    5. PTA of the right external iliac artery.
    6. Implantation of a 8 mm (16 mm long) Absolute self expanding peripheral
    stent in the very distal aspect of the right common iliac artery
    extending down almost the entire length of the right external iliac
    artery.

    HISTORY
    The patient is a very unfortunate, 41-year-old female who has end stage renal
    disease. She developed bacterial endocarditis in the past year or so up in
    Virginia. She was treated for this. She had severe mitral regurgitation.
    She was treated with a prolonged course apparently of antibiotics and was
    treated medically. She has begun to experience symptoms of dyspnea. She had
    an echocardiogram with Doppler study and was found to have severe mitral
    regurgitation. There was concerns about a catheter infection as well. The
    patient was discharged home from Baptist Medical Center and came back with
    acute pulmonary edema. After careful discussion of the various options, she
    was referred for a right and left heart cardiac catheterization.

    PROCEDURE
    The patient was brought to the cardiac catheterization laboratory in very
    stable condition. Both groins were carefully prepped and draped in the usual
    sterile fashion. She was found to have very poor pulses in both groins. We
    elected to use the right side. The patient was anesthetized using 1%
    Xylocaine. She was also given some intravenous sedation. Please see the
    accompanying nursing data sheet for full details regarding her sedation. I
    was able to easily cannulate the right femoral vein without significant
    difficulty. A 7 French venous sheath was then inserted in the right femoral
    vein. We then had a great deal of difficulty trying to cannulate the right
    femoral artery. The pulse was very poor. I decided to proceed on with the
    right heart cardiac catheterization. We advanced the 7 French Swan-Ganz
    catheter up over a J wire and manipulated the catheter out into the patient's
    left pulmonary artery. A pulmonary pressure was obtained as well as a
    pulmonary capillary wedge pressure. The catheter was then pulled back into
    the patient's right ventricle after obtaining an arterial saturation
    measurement within the left pulmonary artery. A right ventricular pressure
    was then obtained. A right atrial pressure was obtained as well. The
    pigtail catheter was then removed.

    After some more difficulty, I was able to successfully cannulate the
    patient's right femoral artery. A J tip wire was manipulated after some mild
    difficulty up the patient's right femoral artery subsequently into the right
    iliac artery up into the aorta. The wire was clearly in the aorta distally.
    I advanced a 5 French sheath carefully up the patient's right femoral artery
    over the J wire. We then advanced a 5 French 4 left Judkins coronary
    diagnostic catheter. All subsequent wire exchanges were performed over an
    exchange wire. Diagnostic coronary angiography was then performed utilizing
    a 5 French 4 left Judkins and a 5 French 4 right Judkins coronary diagnostic
    catheter in order to inject the left and right coronary arteries,
    respectively. A left ventriculogram was then performed in the 30 degree RAO
    projection utilizing a 6 French angled pigtail catheter. This angled pigtail
    catheter was then pulled back across the aortic valve. It should be noted
    that upon obtaining the arterial access, we did measure the arterial
    saturation measurement in the patient's aorta. She was noted to have room
    air oxygen saturation of 90%.

    The patient was noted to have severe mitral regurgitation as expected. Left
    ventricular systolic function, however, was somewhat decreased and the
    ejection fraction was only approximately 50%. In addition, we obtained a net
    for cardiac output by the FICK method of 2.7 liters per minute. I felt that
    the patient might need to have an intraaortic balloon pump placed in order to
    get through cardiac surgery eventually. I felt that it would be helpful to
    perform an abdominal aortogram in order to assess the patient's abdominal
    aorta as well as her iliac arteries. She did have stents in both iliac
    arteries. These were self expanding stents that were easily visualized under
    fluoroscopy.

    I initially performed an abdominal aortogram with the pigtail catheter being
    placed at the level of the first lumbar vertebrae. I was able to visualize
    the patient's abdominal aorta. She did have some narrowing in the abdominal
    aorta but the vessel was patent.

    We then pulled the pigtail catheter down until it was located just above the
    aortic bifurcation. A second abdominal aortogram was performed to look at
    the iliac and femoral arteries. On the left side, the patient was noted to
    have a stent in her left iliac artery that was widely patent. She did have
    some narrowing in her left external iliac artery. This vessel was patent.
    Her right external iliac artery, however, with the catheter passing across it
    appeared to be essentially totally occluded after the takeoff of the right
    internal iliac artery. I removed the catheter and pulled the sheath back
    slightly with the J wire up well into the patient's abdominal aorta. The
    injection was performed through the sheath and the patient was noted to have
    essentially a subtotally occluded right external iliac artery almost along
    its entire length.

    At this point, I felt that we needed to perform some type of catheter based
    intervention to try to obtain patency of the right external iliac artery. I
    felt that if I did not do this that when I pulled the J wire back the patient
    could develop an ischemic right leg. I felt this was essentially an
    emergency. In addition, I also felt that the patient may need to have an
    intraaortic balloon pump and achieve an access for this. I therefore
    performed an additional cineangiogram through the sheath in the 30 degree LAO
    projection. This laid out the takeoff of the right external iliac artery
    very nicely. I then selected a 5 mm peripheral balloon catheter, the balloon
    being 40 mm in length. A total of three balloon inflations were made with
    this catheter. We then deflated the balloon catheter and removed it.
    Subsequent cineangiograms revealed a significant improvement at the PTCA
    site. I then selected a 6 mm peripheral balloon catheter with the balloon
    being 40 mm in length. Three balloon inflations were made with this
    catheter. We then deflated the balloon catheter and removed it. Subsequent
    cineangiograms revealed a much more widely patent right external iliac artery
    now. There was one area, however, at the takeoff of the right external iliac
    artery where the artery was still very tightly narrowed. I felt that we
    needed to place a self expanding stent and would have to place the most
    distal part of the stent up into the distal aspect of the patient's right
    common iliac artery. I therefore selected an 8 mm Absolute self expanding
    stent with the stent being 60 mm in length. I brought this stent down to
    what I felt was then most optimal position. When we had it in this position,
    we removed the deployment sheath. The stent appeared to expand very nicely.

    I then postdilated the stent with a 6 mm Agile Track balloon catheter we
    utilized earlier. Two balloon inflations were made within the stent.

    We then deflated the balloon catheter and removed it. The right iliac artery
    and right external iliac artery were now widely patent. There was excellent
    flow up the vessel. We could see runoff into the contralateral iliac artery
    as well. In addition, the patient now had a normal pressure wave form
    tracing at the sheath insertion site in the right femoral artery.

    The patient tolerated the procedure quite well. There were no complications.
    She was taken to the cardiac catheterization laboratory holding area in order
    to have her sheaths pulled.

    RESULTS

    HEMODYNAMICS
    1. Mean right atrial pressure is 17.
    2. Right ventricle pressure is 65/13.
    3. Mean pulmonary artery pressure is 65/27 with a mean of 42.
    4. Mean pulmonary artery capillary wedge pressure is 29 with a V wave
    equal to 50.
    5. Left ventricular pressure is 87/21.
    6. Aortic pressure 94/77 with a mean of 85.
    7. Oxygen saturation: Aorta 90%, pulmonary artery 42%, cardiac output
    FICK 2.7 liters per minute.

    FEMORAL ARTERY PRESSURES
    1. Prior to stent placement the right femoral artery is 59/54 with a mean
    of 57.
    2. After stent placement right femoral artery 106/72 with a mean of 84.

    ANGIOGRAPHY
    1. The left main coronary artery is normal.
    2. The left anterior descending coronary artery is normal.
    3. The left circumflex coronary artery is normal.
    4. The right coronary artery is a large and dominant vessel which is
    normal.
    5. Left ventriculogram reveals a dilated left ventricle. Left ventricular
    systolic function is somewhat reduced and the overall left ventricular
    ejection fraction was estimated to be approximately 50%. There was
    severe mitral regurgitation detected. The left atrium is markedly
    dilated.
    6. Abdominal aortogram reveals an unremarkable abdominal aorta. The right
    common iliac artery has a stent present which is patent. The right
    external iliac artery is subtotally occluded at its takeoff. The left
    common iliac artery has stents present that are widely patent. There
    is some mild narrowing noted within the stent. The left external
    iliac artery has a 40 to 50% obstructive narrowing noted within it.
    7. After successful PTA and subsequent implantation of an 8 mm (16 mm
    long) Absolute self expanding stent into the distal right common iliac
    artery extending along the entire length of the right external iliac
    artery, the subtotally occluded right external iliac artery
    preintervention was reduced to no residual narrowing postintervention.
    There is excellent flow in the distal vessel. There is no dissection.

    CONCLUSION
    1. Marked pulmonary hypertension secondary to elevated pulmonary capillary
    wedge pressure secondary to severe mitral regurgitation.
    2. Reduced cardiac output secondary to severe mitral regurgitation.
    3. Dilated left ventricle with reduced left ventricular systolic function.
    4. Markedly dilated left atrium.
    5. Angiographically normal coronary arteries.
    6. Abdominal aortogram revealing widely patent stents in both common iliac
    arteries bilaterally with the right external iliac artery being
    subtotally occluded.
    7. Successful PTA with subsequent implantation of an 8 mm (16 mm long)
    Absolute self expanding peripheral stent in the very distal aspect of
    the right common iliac artery extending almost the entire length of
    the right external iliac artery. The subtotally occluded right
    external iliac artery preintervention was reduced to no residual
    narrowing postintervention. There was excellent flow in the distal
    vessel. There was no evidence of dissection.
    Jammie Barsamian, CPC, CCC, CEMC, CCS-P, CPMA

  2. #2
    Location
    Birmingham, Alabama
    Posts
    889
    Default
    Quote Originally Posted by jlb102780 View Post
    Hi everyone! Here's another really long report that I'm stuck on. Any help coding this would be so wonderful




    NAME OF TEST:
    1. Left and right heart cardiac catheterization.
    2. Coronary angiography.
    3. Left ventriculography.
    4. Abdominal aortogram.
    5. PTA of the right external iliac artery.
    6. Implantation of a 8 mm (16 mm long) Absolute self expanding peripheral
    stent in the very distal aspect of the right common iliac artery
    extending down almost the entire length of the right external iliac
    artery.

    HISTORY
    The patient is a very unfortunate, 41-year-old female who has end stage renal
    disease. She developed bacterial endocarditis in the past year or so up in
    Virginia. She was treated for this. She had severe mitral regurgitation.
    She was treated with a prolonged course apparently of antibiotics and was
    treated medically. She has begun to experience symptoms of dyspnea. She had
    an echocardiogram with Doppler study and was found to have severe mitral
    regurgitation. There was concerns about a catheter infection as well. The
    patient was discharged home from Baptist Medical Center and came back with
    acute pulmonary edema. After careful discussion of the various options, she
    was referred for a right and left heart cardiac catheterization.

    PROCEDURE
    The patient was brought to the cardiac catheterization laboratory in very
    stable condition. Both groins were carefully prepped and draped in the usual
    sterile fashion. She was found to have very poor pulses in both groins. We
    elected to use the right side. The patient was anesthetized using 1%
    Xylocaine. She was also given some intravenous sedation. Please see the
    accompanying nursing data sheet for full details regarding her sedation. I
    was able to easily cannulate the right femoral vein without significant
    difficulty. A 7 French venous sheath was then inserted in the right femoral
    vein. We then had a great deal of difficulty trying to cannulate the right
    femoral artery. The pulse was very poor. I decided to proceed on with the
    right heart cardiac catheterization. We advanced the 7 French Swan-Ganz
    catheter up over a J wire and manipulated the catheter out into the patient's
    left pulmonary artery. A pulmonary pressure was obtained as well as a
    pulmonary capillary wedge pressure. The catheter was then pulled back into
    the patient's right ventricle after obtaining an arterial saturation
    measurement within the left pulmonary artery. A right ventricular pressure
    was then obtained. A right atrial pressure was obtained as well. The
    pigtail catheter was then removed.

    After some more difficulty, I was able to successfully cannulate the
    patient's right femoral artery. A J tip wire was manipulated after some mild
    difficulty up the patient's right femoral artery subsequently into the right
    iliac artery up into the aorta. The wire was clearly in the aorta distally.
    I advanced a 5 French sheath carefully up the patient's right femoral artery
    over the J wire. We then advanced a 5 French 4 left Judkins coronary
    diagnostic catheter. All subsequent wire exchanges were performed over an
    exchange wire. Diagnostic coronary angiography was then performed utilizing
    a 5 French 4 left Judkins and a 5 French 4 right Judkins coronary diagnostic
    catheter in order to inject the left and right coronary arteries,
    respectively. A left ventriculogram was then performed in the 30 degree RAO
    projection utilizing a 6 French angled pigtail catheter. This angled pigtail
    catheter was then pulled back across the aortic valve. It should be noted
    that upon obtaining the arterial access, we did measure the arterial
    saturation measurement in the patient's aorta. She was noted to have room
    air oxygen saturation of 90%.

    The patient was noted to have severe mitral regurgitation as expected. Left
    ventricular systolic function, however, was somewhat decreased and the
    ejection fraction was only approximately 50%. In addition, we obtained a net
    for cardiac output by the FICK method of 2.7 liters per minute. I felt that
    the patient might need to have an intraaortic balloon pump placed in order to
    get through cardiac surgery eventually. I felt that it would be helpful to
    perform an abdominal aortogram in order to assess the patient's abdominal
    aorta as well as her iliac arteries. She did have stents in both iliac
    arteries. These were self expanding stents that were easily visualized under
    fluoroscopy.

    I initially performed an abdominal aortogram with the pigtail catheter being
    placed at the level of the first lumbar vertebrae. I was able to visualize
    the patient's abdominal aorta. She did have some narrowing in the abdominal
    aorta but the vessel was patent.

    We then pulled the pigtail catheter down until it was located just above the
    aortic bifurcation. A second abdominal aortogram was performed to look at
    the iliac and femoral arteries. On the left side, the patient was noted to
    have a stent in her left iliac artery that was widely patent. She did have
    some narrowing in her left external iliac artery. This vessel was patent.
    Her right external iliac artery, however, with the catheter passing across it
    appeared to be essentially totally occluded after the takeoff of the right
    internal iliac artery. I removed the catheter and pulled the sheath back
    slightly with the J wire up well into the patient's abdominal aorta. The
    injection was performed through the sheath and the patient was noted to have
    essentially a subtotally occluded right external iliac artery almost along
    its entire length.

    At this point, I felt that we needed to perform some type of catheter based
    intervention to try to obtain patency of the right external iliac artery. I
    felt that if I did not do this that when I pulled the J wire back the patient
    could develop an ischemic right leg. I felt this was essentially an
    emergency. In addition, I also felt that the patient may need to have an
    intraaortic balloon pump and achieve an access for this. I therefore
    performed an additional cineangiogram through the sheath in the 30 degree LAO
    projection. This laid out the takeoff of the right external iliac artery
    very nicely. I then selected a 5 mm peripheral balloon catheter, the balloon
    being 40 mm in length. A total of three balloon inflations were made with
    this catheter. We then deflated the balloon catheter and removed it.
    Subsequent cineangiograms revealed a significant improvement at the PTCA
    site. I then selected a 6 mm peripheral balloon catheter with the balloon
    being 40 mm in length. Three balloon inflations were made with this
    catheter. We then deflated the balloon catheter and removed it. Subsequent
    cineangiograms revealed a much more widely patent right external iliac artery
    now. There was one area, however, at the takeoff of the right external iliac
    artery where the artery was still very tightly narrowed. I felt that we
    needed to place a self expanding stent and would have to place the most
    distal part of the stent up into the distal aspect of the patient's right
    common iliac artery. I therefore selected an 8 mm Absolute self expanding
    stent with the stent being 60 mm in length. I brought this stent down to
    what I felt was then most optimal position. When we had it in this position,
    we removed the deployment sheath. The stent appeared to expand very nicely.

    I then postdilated the stent with a 6 mm Agile Track balloon catheter we
    utilized earlier. Two balloon inflations were made within the stent.

    We then deflated the balloon catheter and removed it. The right iliac artery
    and right external iliac artery were now widely patent. There was excellent
    flow up the vessel. We could see runoff into the contralateral iliac artery
    as well. In addition, the patient now had a normal pressure wave form
    tracing at the sheath insertion site in the right femoral artery.

    The patient tolerated the procedure quite well. There were no complications.
    She was taken to the cardiac catheterization laboratory holding area in order
    to have her sheaths pulled.

    RESULTS

    HEMODYNAMICS
    1. Mean right atrial pressure is 17.
    2. Right ventricle pressure is 65/13.
    3. Mean pulmonary artery pressure is 65/27 with a mean of 42.
    4. Mean pulmonary artery capillary wedge pressure is 29 with a V wave
    equal to 50.
    5. Left ventricular pressure is 87/21.
    6. Aortic pressure 94/77 with a mean of 85.
    7. Oxygen saturation: Aorta 90%, pulmonary artery 42%, cardiac output
    FICK 2.7 liters per minute.

    FEMORAL ARTERY PRESSURES
    1. Prior to stent placement the right femoral artery is 59/54 with a mean
    of 57.
    2. After stent placement right femoral artery 106/72 with a mean of 84.

    ANGIOGRAPHY
    1. The left main coronary artery is normal.
    2. The left anterior descending coronary artery is normal.
    3. The left circumflex coronary artery is normal.
    4. The right coronary artery is a large and dominant vessel which is
    normal.
    5. Left ventriculogram reveals a dilated left ventricle. Left ventricular
    systolic function is somewhat reduced and the overall left ventricular
    ejection fraction was estimated to be approximately 50%. There was
    severe mitral regurgitation detected. The left atrium is markedly
    dilated.
    6. Abdominal aortogram reveals an unremarkable abdominal aorta. The right
    common iliac artery has a stent present which is patent. The right
    external iliac artery is subtotally occluded at its takeoff. The left
    common iliac artery has stents present that are widely patent. There
    is some mild narrowing noted within the stent. The left external
    iliac artery has a 40 to 50% obstructive narrowing noted within it.
    7. After successful PTA and subsequent implantation of an 8 mm (16 mm
    long) Absolute self expanding stent into the distal right common iliac
    artery extending along the entire length of the right external iliac
    artery, the subtotally occluded right external iliac artery
    preintervention was reduced to no residual narrowing postintervention.
    There is excellent flow in the distal vessel. There is no dissection.

    CONCLUSION
    1. Marked pulmonary hypertension secondary to elevated pulmonary capillary
    wedge pressure secondary to severe mitral regurgitation.
    2. Reduced cardiac output secondary to severe mitral regurgitation.
    3. Dilated left ventricle with reduced left ventricular systolic function.
    4. Markedly dilated left atrium.
    5. Angiographically normal coronary arteries.
    6. Abdominal aortogram revealing widely patent stents in both common iliac
    arteries bilaterally with the right external iliac artery being
    subtotally occluded.
    7. Successful PTA with subsequent implantation of an 8 mm (16 mm long)
    Absolute self expanding peripheral stent in the very distal aspect of
    the right common iliac artery extending almost the entire length of
    the right external iliac artery. The subtotally occluded right
    external iliac artery preintervention was reduced to no residual
    narrowing postintervention. There was excellent flow in the distal
    vessel. There was no evidence of dissection.
    quite an extensive procedure...here goes:
    part 1
    93526(26) includes all catheter placements
    93556(26)
    93555(26)
    93545
    93543

    part 2
    37205/75960(26)
    35473/75962 suboptimal results are documented allowing for stent and plasty.
    75625(26,59) medical necessity is documented allowing for aortogram w/heart cath.
    75716(26,59) medical necessity is documented...

    Ordinarily the aortogram and extremity angiogram would be included (IMO)with the heart cath but with a separately documented medical reason, and a thorough interpretation of these, they are allowed.

    Also, clear documentation of suboptimal results of the iliac angioplasty allow for both interventional procedures to be billed.

    HTH
    Danny L. Peoples
    CIRCC,CPC

  3. #3
    Location
    Jacksonville Florida
    Posts
    126
    Default
    Thank you sooooo much Danny!
    Jammie Barsamian, CPC, CCC, CEMC, CCS-P, CPMA

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