Ask Dr. Z

"Left heart catherization, coronary angiography and left ventriculography. Percutaneous transluminal angioplasty with coronary stent placement in the mid LAD. Percutaneous transluminal angioplasty of the diagonal branch of the LAD. Femoral angiography and placement of the 8 French Angio-seal. Fractional flow reserve study of the LAD." Please tell me if the coding is correct. I have coded: 93458- 2659, 92941-LD, 36245-59, 36140-59, 75710-2659, and 93571-26LD.

It is said that aspiration thrombectomy is included in stent placement. The only code for stent placement I can find that says aspiration thrombectomy is included is 92941. Will you please show where in the CPT Codebook it says aspiration thrombectomy is included in code 92928?

Dr. Z - We have a case where the patient presented with acute MI. The patient was taken emergently to the cath lab. During the LHC, it was discovered the the patient had 100% occlusion in the mid-RCA secondary to ISR, duration of occlusion unknown. The patient also had 99% mid-LAD stenosis. We attempted intervention on the RCA CTO, using a Pilot 50, but the wire was going into the subintimal space, and further intervention on the CTO was stopped. Attention was turned to the LAD, and PCI/DES was performed. I bill for the hospital side. Would we code this as an attempted CTO, 92943-74, RC and C9600-LD, or would the hierarchy rule not apply since the patient was taken emergently to the cath lab for acute MI, making our codes C9606-LD and 92943-74? Thank you.

Patient with AMI taken to lab. Diagnostic cardiac cath (93455) was performed, and upon trying to intervene on the culprit lesion the physician was unsuccessful in crossing the lesion and the procedure was discontinued. The physician does not document the intended procedure (i.e., angioplasty alone, angioplasty with stent, angioplasty with atherectomy, or all three). In the absence of clear documentation of the intended PCI procedure, considering code 92941 requires combination of angioplasty with either stent and/or atherectomy, should we report code 92920-74? Being conservative rather than assuming without documentation that a stent and/or atherectomy was planned?

Would this be reported with codes 33967 and 92941? "A BMW angioplasty guidewire was advanced into the LAD but would not cross the lesion. I placed a guide liner for additional support. A Choice PT wire was then used to cross the obstruction, and the lesion was dilated with a 2.5 mm balloon. I then deployed a 3.0 x 15 mm Xience drug-eluting stent. Repeat angiography was performed. During the follow-up imaging a small bubble was introduced into the circumflex, and the patient subsequently deteriorated rapidly. A code was called, and the patient was subsequently intubated and ACLS protocols initiated. I was able to exchange the sheath in the RFA for an 8 French balloon pump sheath and then placed a 40 cc intra-aortic balloon pump into the descending thoracic aorta."

"Patient brought to cath lab emergently. A 100% occluded vessel was located in the LD, RC, and LC. Our culprit lesion was in the LD and treated with a stent. The LC was treated with an Aspiration thrombectomy of the OM2. No angioplasty or stenting was preformed in this vessel. Then the RC an attempted angioplasty was preformed since they were not able to cross the lesion they are planning on brining the patient back at a later time."

We know that the aspiration is included in the primary intervention of the same vessel. In this case would we be able to bill code 92941-LD with 93799-LC for the thrombectomy that was completed in the LC?

"Aspiration thrombectomy of OM 2. Thrombus was visualized in the distal arm to causing a 100% occlusion/TIMI 0 flow. Following the intervention of the LAD, the Choice PT was reintroduced and used to cross the thrombotic lesion. Aspiration thrombectomy performed using priorityONE 6 French aspiration catheter."

Would this scenario be coded as 92941 or 92920 since the MI occurred during a non-emergent LHC? 

"Emergent PCI indicated for distally embolized atheroembolic material in LM occluding LC after diagnostic LHC. PTCA with 2.5 mm x 12 mm in mL CX restoring TIMI II flow in OM2. TIMI 0 flow remained in OM3. Minamo wire was unable to transverse thrombus in OM3. A Sion black wire was placed in OM3 branch, which transversed the thrombus and was dilated. IVUS in mid OM3 showed embolized atheroma with thrombus. Pronto LP placed in OM3 for aspiration, which did not improve TIMI flow. Dilations completed with 2 x 10 compliant balloon restoring TIMI I flow distal OM1. Dilation in OM2 completed d/t thrombotic debris. OM2 appeared normal with TIMI III flow. Pronto LP placed distally in OM3 and distal vasculature bathed in 600mg of IC Cardene followed by aspiration thrombectomy. This restored TIMI III flow in the vessel; however, residual thrombus was identified."

We had a patient who had a left heart catheterization with PTCA and stent placement in the left circumflex. The patient was transferred back to a room and about a 1/2 hour after that procedure she developed acute onset substernal chest pain, ST elevation, nausea, vomiting, and diaphoresis. She was taken back to the cath lab and showed to have acute stent thrombosis after the previous stent placement. A successful PTCA of the stent thrombosis was done, and a stent was also placed distally in the left circumflex to ensure that there was no distal edge dissection. We billed codes 93458 and 92928-LC for the first procedure and codes 93454, 92928-LC, and 92941-LC (for PTCA of stent thrombosis) for the second procedure. Can we bill for both procedures done on the same day since the code is the same for the stent placement? And can we bill for two separate heart catheterization codes if they were done on both procedures?