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4 or more stents in a single coronary vessel at same session

Tammy Posted Thu 02nd of April, 2015 12:19:50 PM

I have a patient that my physician put 5 stents in the right coronary artery at the same session when the patient was having a non-ST elevation myocardial infarction. He also used atherectomy to remove much of the total occlusion. He is billing a 92941RC, 9297826, 947582659. I researched and Medicare LCD L34139 states that "However, if four or more stents are placed in a single vessel, then it would be considered an "unusual procedural service" and eligible for additional reimbursement equivalent to that of an additional treated vessel."
I am not sure which additional code to use for the 5th stent. I have enclosed the dictation for review. Any help would be greatly apprectiated.
The right radial artery was cannulated with a 6-French sheath. A multipurpose A2 catheter was passed into the left ventricle and used for hand injection left ventriculogram. Catheter was then pulled back and used for nonselective injection of the right coronary artery, which one could see was totally occluded distally, and also used to inject the left coronary artery. Following left coronary angiograms, we decided to treat the stenosis in the distal right.

The previous catheter was replaced with a hockey-stick II guiding catheter. We were able to pass a BMW wire down through the occlusion and into the distal vessel, but it appeared that it was not in the vessel we wanted it to be. We therefore chose a "Pronto LP" device and passed it down into the area of occlusion. Once we sucked this out, although we did not see any thrombus, we did have flow into the distal vessel and could see that the wire was indeed in a side branch. The wire was pulled back and advanced down into the distal vessel. There was also a stenosis at the place where the posterolateral branch turned out over the ventricle from the AV groove. We crossed this area with a wire. We then chose a Boston Scientific 2.5 x 12 mm balloon, and passed it down through the total occlusion. We dilated proximally through the vessel. We then chose a 2.5 x 24 mm Promus Premier Stent. We used this on the most distal stenosis extending so that it turned over the left ventricle where the posterolateral branch left the left ventricle. We then used a 2.75 x 38 mm Promus Premier Stent and passed it just inside the previous stent and extended it proximally. We initially had trouble passing this across some stenoses in the midportion of the right coronary artery, actually proximal to where the total occlusion had been. We added a second wire, a sport wire. This was passed down into the distal right coronary artery and posterolateral branch. We then were able to pass the 38 mm long Promus Premier Stent down so that it extended just inside the first stent. We then extended that one proximally with a 2.75 x 38 mm stent, and then from there to the ostium with a 3 x 28 mm stent. This came nearly to the ostium. We did repeat intravascular ultrasound and took more pictures. This showed that the stent was quite well deployed throughout , but there were couple of areas of malapposition where there was plaque and some angulation of the vessel. Nonetheless, we went back with a 3.25 x 30 mm NC Quantum Apex and postdilated from distal to the area of total occlusion all the way back up through the ostium of the first stent. We did intravascular ultrasound, and showed that stent apposition was improved although it was not perfect because of the calcified angulations in the vessel. At any rate, we then saw that there was some stenosis right at the ostium of the right coronary artery proximal to the most proximal stent. We decided to treat this, and used a 3.5 x 16 mm Promus Premier Stent. We repeated intravascular ultrasound, and could see that the stent extended about a millimeter outside the ostium and was in the aorta. We decided to treat the ostium of the stent with a flash mini ostial system, and afterwards repeated intravascular ultrasound. It appears that the struts that were extending out into the aorta have been now moved back against the aortic wall near the ostium. The final angiographic appearance is very good.

The guiding catheter was removed over a starter wire. The sheath was removed from the right radial artery. Hemostasis was obtained by means of an R-band.

SuperCoder Answered Fri 03rd of April, 2015 00:47:00 AM

AAE does not provide coding for operative reports and chart notes.

SuperCoder offers SuperCoding on Demand (SOD) ( for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail for more information.

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