Ask Dr. Z

"A pre-existing RFA IABP was exchanged over a wire for sequential dilation of the RFA access site, followed by insertion of a 14 French Impella sheath. A 6 French sheath was inserted in the LFA via modified Seldinger technique. The Impella wire was then advanced into the LV, but the device could not be advanced beyond the level of a distal aorta calcified plaque. Accordingly, the sheath was removed from the RFA and exchanged for a long sheath, with subsequent dilation of the distal aortic plaque over a 035 wire with a 10 x 40 Bard Ultraverse balloon, followed by successful advancement of the Impella device over the Impella wire across the aortic valve and into the apex of the left ventricle with initiation of LV support with a good and stable hemodynamic tracing." Can we charge for the dilation of the aorta because there was plaque, or is it included because it was for advancing the Impella device? Would that be 37246 with 33990 and 33968 (IABP was removed)?