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Is it 93458?

  1. #1
    Default Is it 93458?
    Exam Training Packages
    Is it still appropriate to bill as 93458?

    PROCEDURES PERFORMED:

    -- Left heart catheterization.
    -- Left coronary angiography.

    RECOMMENDATIONS:
    The patient should continue with the present medications.
    The patient's anti-anginal regimen should be further intensified.

    INDICATIONS: Angina/MI: stable angina.

    CORONARY VESSELS: The coronary circulation is right dominant. Small
    non-flow limiting dissection noted at the distal LMCA/LAD ostium. This is
    unchanged from previous image from yesterday and is felt to be stable.

    Ramus lesion is also unchanged and since it is a small vessel, best
    treatment option is medical therapy. Mid LAD: There was a 100 % stenosis.
    1st diagonal: There was a 99 % stenosis. Mid circumflex: Angiography
    showed minor luminal irregularities.

    PROCEDURE: The risks and alternatives of the procedures and conscious
    sedation were explained to the patient and informed consent was obtained.
    The patient was brought to the cath lab and placed on the table. The
    planned puncture sites were prepped and draped in the usual sterile
    fashion.

    -- Right femoral artery access. The puncture site was infiltrated with
    local anesthetic. The vessel was accessed using the modified Seldinger
    technique, a wire was threaded into the vessel, and a sheath was advanced
    over the wire into the vessel.

    -- Left heart catheterization. A catheter was advanced to the ascending
    aorta. After recording ascending aortic pressure, the catheter was
    advanced across the aortic valve and left ventricular pressure was
    recorded. Imaging was performed using an RAO projection.

    -- Left coronary artery angiography. A catheter was advanced to the aorta
    and positioned in the vessel ostium under fluoroscopic guidance.
    Angiography was performed in multiple projections using hand-injection of
    contrast.

    COMPLICATIONS:
    There were no adverse outcomes.
    PROCEDURE COMPLETION: The patient tolerated the procedure well. TIMING:
    Test started at 09:48. Test concluded at 10:00. RADIATION EXPOSURE:
    Fluoroscopy time: 0.7 min.
    HEMOSTASIS:
    The sheath was removed. The site was compressed manually. Hemostasis was
    successful.

  2. Default 93458
    Yes, you can bill 93458, the description states coronary artery(s) so you can bill it even if they only image one.

  3. #3
    Default
    Not sure you can bill for this because it sounds like from the above dictation that a HTC was done the day before. If a HTC was done the day before you will need to find out from the doctor why it was being performed agian the next day (i.e. medical necessity). I do not see a statement/reason why the pt returned to the cath lab.

  4. Default
    Quote Originally Posted by Misty Dawn View Post
    Not sure you can bill for this because it sounds like from the above dictation that a HTC was done the day before. If a HTC was done the day before you will need to find out from the doctor why it was being performed agian the next day (i.e. medical necessity). I do not see a statement/reason why the pt returned to the cath lab.
    The physician should have said recurrent angina maybe? But yes this is a LHC since the aortic valve was crossed.
    Theresa CCS-P CPMA CCC ICDCT-CM

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