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Coronary Angiography, Abd Aortogram & BLE runoff

Kaitlyn Posted Thu 13th of February, 2014 11:19:46 AM

I am having trouble coding this procedure. My provider performed a 1. Coronary Angiography
2. Abdominal aortogram with bilateral lower extremity runoff
3. Selective Left Iliac angiogram

I believe the correct codes are '93458-26, 36245-50/59 and a 75716-59/26' can you confirm If I am missing anything or if this is correct?

PROCEDURE: After obtaining informed consent, the patient was taken to the
cardiac catheterization laboratory and prepped and draped in a sterile
manner. The area over the left femoral artery was anesthetized with the
use of subcutaneous lidocaine. Initially, an attempt made to advance a
6-French sheath into the groin. However, there was resistance met. This
was removed and the 6-French sheath dilator was advanced via the wire.
The dilator was removed, and the sheath carefully again advanced,
however, could not fully inserted. The 6-French sheath was then exchanged
successfully for a 5-French sheath. A 5-French JL4 diagnostic catheter
was advanced to the aortic root and the left main coronary artery
engaged. Selective angiograms were performed in multiple views. This
catheter was then exchanged for a 6-French 3DRC diagnostic catheter, with
which the right coronary artery was engaged. Selective angiograms were
performed in multiple views. Unsuccessful attempts were made to enter the
left ventricle with this catheter. The catheter was then pulled down to
just superior to the aortic bifurcation and an abdominal aortogram with
bilateral lower extremity runoff was performed via hand injection. The
catheter was then pulled back and the left femoral artery sheath was used
to perform a selective left iliac angiogram. The procedure was ended. The
sheath was subsequently removed and pressure held until hemostasis
obtained in the catheter lab.

Contrast: 110 mL.

SuperCoder Answered Fri 14th of February, 2014 04:52:45 AM

Based on the information given, the provider didn't cross the aortic valve and performed only coronary angiography, which would be 93454-26 (instead of 93458). Without knowing the medical necessity and findings for the other imaging, it's tough to say what can be coded. For instance, the iliac imaging may have been to help with viewing access for possible closure device deployment (and then maybe decided on hemostasis patch instead), and that isn't separately reportable. If complete extremity angiography was warranted and provided, then 75716-59/26 could be correct. Note that the MD didn't perform bilateral selective cath placement (36245.50).

Kaitlyn Posted Fri 14th of February, 2014 12:46:19 PM

Here is the rest of the report
Can you confirm the '75716-59/26' based off the remaining report. Are there any other codes that I am missing?

FINDINGS:

RCA: The RCA is heavily calcified throughout the vessel. It has moderate
diffuse disease and tapers to a long 70% lesion in the mid segment.
Distally, the vessel has mild diffuse disease. The right PDA and right
PLA have mild diffuse disease. This vessel supplies extensive type 3
collaterals to the distal LAD. Competitive flow is seen on imaging within
the distal and apical LAD.

LEFT MAIN: Heavily calcified with moderate diffuse disease.

LEFT CIRCUMFLEX: The AV groove left circumflex again is heavily calcified
throughout the proximal to mid segment. It tapers to a 50% proximal
lesion in the mid segment. There is moderate diffuse disease, high OM-1.
There is a small caliber vessel with distal mild disease. OM-2 is small
caliber with mild diffuse disease. OM-3 is bifurcating with moderate
diffuse disease. Left PLA-1 is angiographically normal, but small
caliber. Distally within the AV groove left circumflex there is a 60%
lesion.

LAD: The LAD is heavily calcified proximal to mid with moderate diffuse
disease proximally. It tapers to a subtotal occlusion after the takeoff
of a large first septal. There is a following short mid segment with
moderate diffuse disease. D1 has moderate diffuse
disease and is relatively small caliber. It also is subtotally occluded in
the mid segment. D2 comes off the subtotally
occluded segment and has ostial disease of approximately 50%. The
remainder of the vessel has mild diffuse disease. D3 has mild diffuse
disease. The distal to apical LAD is filled retrograde via type III
collaterals from the RCA. There is competitive flow seen.

Abdominal aortogram reveals a heavily calcified aortic bifurcation and
bilateral common and external iliacs. The right common iliac artery has
moderate diffuse disease and is heavily calcified. The right external
iliac has moderate diffuse disease and again is heavily calcified. The
right common femoral artery shows moderate diffuse disease and is heavily
calcified.

CONCLUSIONS:
1. Severe disease of the LAD. The mid LAD is subtotally occluded. The
vessel is distally collateralized via type III collaterals from the RCA.
2. Moderate disease of the left circumflex.
3. 70% mid RCA lesion, heavily calcified.
4. Heavily calcified major vessels.
5. Moderate diffuse PAD of the left common femoral and left common iliac
artery. Insertion of a 5-French resulted in TIMI 2 flow throughout this
region. Would recommend consider alternate vessels for percutaneous
access in the future.

RECOMMENDATIONS:
Titrate medications for angina given the patient's overall prognosis. We
will discuss with family percutaneous intervention versus conservative
medical therapy. The patient is a poor candidate for CABG based on his
poor respiratory status.

SuperCoder Answered Fri 14th of February, 2014 13:48:22 PM

Please contact Customer Service Manney -at 866-228-9252 Extn : 4165

Thanks,

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