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Code This!

Scenario Week of November 14, 2011:
View Current Scenario

BRIEF HISTORY:
The patient is a 44-year-old cigarette smoker with a markedly positive family history of coronary artery disease who has an electrocardiogram showing an old anterior septal myocardial infarction. Nuclear study showed a fixed anterior defect. He has had episodes of chest pain and coronary angiography has been recommended.

DESCRIPTION OF THE PROCEDURE:
One percent lidocaine was infiltrated over the right femoral artery. A 6-French sheath was placed in the right femoral artery. Diagnostic coronary angiography was performed with a 6-French JL-4 and 6-French JR-4 diagnostic catheters. Following coronary angiography, a 6-French pigtail catheter was placed in the left ventricle where left ventriculography was performed with 36 cc of contrast injected at 12 cc per second. At the conclusion of the procedure, the catheter and sheath were removed and Angio-Seal plug was deployed.

TECHNICAL FACTORS:
Medications: Fentanyl 100 mcg and Versed 2 mg.
Contrast: Isovue 130 cc.
Fluoroscopy time: 2 minutes.

HEMODYNAMICS:

Opening aortic pressure 103/58.

Following coronary angiography, the left ventricular pressure was 107/12.

There was no aortic stenosis on left heart pullback.

CORONARY ANGIOGRAPHY:

There was no significant obstructive coronary artery disease in this right dominant system. There is minimal to no stenosis in the distal left main.

The left circumflex artery is a moderate-sized vessel filling a large first obtuse marginal and diminutive second obtuse marginal and there is no significant disease.

The left anterior descending coronary artery is a large vessel which extends to the apex. It fills several small diagonal branches. There are no significant stenoses. There is a large ramus intermedius which fills the lateral wall. It, too, has no significant disease.

The right coronary artery is a large dominant vessel filling a moderate-sized posterior descending artery and two larger posterolateral branches. There are no significant obstructions in the right coronary artery.

LEFT VENTRICULOGRAPHY:

The left ventricular systolic function is normal. There are no regional wall motion abnormalities. There is no mitral regurgitation.

DIAGNOSTIC IMPRESSION:

  1. There is no significant obstructive coronary artery disease in this right dominant system. There is a plaque in the distal left main, but there is no significant obstruction.
  2. Left ventricular systolic function is normal. There is no evidence of previous anterior wall myocardial infarction.

PLAN:

I do not have a definite explanation for the patient's abnormal electrocardiogram or abnormal nuclear study. Coronary spasm remains in the differential diagnosis and we have encouraged him to completely discontinue smoking. He certainly can take nitroglycerin on an as-needed basis in the future. I would continue aspirin indefinitely.


ANSWERS
ICD-9-CM Diagnosis codes
794.31 Nonspecific abnormal electrocardiogram (ECG) (EKG)
794.39 Other nonspecific abnormal cardiovascular system function study
305.1 Tobacco use disorder
V17.3 Ischemic heart disease

RATIONALE
There were no significant findings on the catheterization therefore the reason for the procedure should be reported as first listed diagnosis. The old anterior infarction mentioned in the beginning of the report is conflicted and made obsolete by the physician’s comment that “there is no evidence of previous anterior wall myocardial infarction. And although the physician suspects coronary spasms in his plan, this cannot be reported as a final diagnosis as it is not confirmed. The Official ICD-9-CM Guidelines for Coding and Reporting Section IV.I. states that an uncertain diagnosis cannot be reported for an outpatient encounter. The chest pain should not be reported either as it is not a current diagnosis. The patient has had chest pain but is not complaining of it during this encounter, making this a past problem. Per Coding Guideline Section IV.K., conditions that existed and were treated previously but are no longer present should not be reported. This leaves only the abnormal electrocardiogram and stress test to be the reason for the catheterization, followed by tobacco abuse and family history of CAD. These two additional codes should be reported on a patient receiving any type of cardiovascular work-up as they are identified as significant risks for a serious cardiac event.

CPT Codes
93458 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed
G0269 Placement of occlusive device into either a venous or arterial access site, postsurgical or interventional procedure (e.g., angioseal plug, vascular plug)

RATIONALE:
A left heart catheterization with both left and right coronary artery studies was performed using two catheters. The physician does discuss entering the left ventricle and performing a ventriculography making all of the components of 93458 present. The physician also states that an angioseal is deployed the end of the procedure. If the payer accepts HCPCS code, G0269 should be reported for this procedure.

 
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