Ask Dr. Z

Dr Z, one of our commercial payers is denying payment for 93531, 93567 and 93565, stating it is included in 95986. They state: "Coding guidelines for valvuloplasty state: 'Do you code for heart catheterization if performed during the valve intervention to document pre- and post-intervention findings. All catheter placements, contrast injections, imaging and S&I to perform the valve replacement are bundled.' The business office and cath lab are requesting I persue this further. Part of my problem is I am not certain the H/C is reportable. I don't see it dictated as a separate diagnostic procedue I would really appreciate your opinion on whether or not we can report 93531,93564 and 93565 in addition to 92986. Thank you JM Technical Procedure(s): 1.Procedure(s) (LRB): CD COMBINED RHC & LHC RETROGRADE (CHD) (N/A) 2. CD VALVULOPLASTY AORTIC (N/A) INDICATIONS/BRIEF CLINICAL HISTORY who has been followed for a aortic valve stenosis. has been healthy with no significant cardiovascular complaints except new onset fatigue with activity. presents for cardiac catheterization and balloon aortic valvuloplasty. PROCEDURE NOTE Upon arrival to the catheterization lab, was placed under general anesthesia and was endotracheally intubated by the staff anesthesiologist. He was secured to the cath table and was prepped and draped in a sterile fashion. 1% Lidocaine was infiltrated into the skin and soft tissue around the right and left femoral vessels in order to achieve local anesthetic effect. A modified Seldinger technique was used to obtain arterial and venous access. A 5F sheath was placed in the right and left femoral vein. A 5F sheath was placed in the right and left femoral artery. 100 Units/kg of heparin were given through the venous sheath. Antibiotics were given. A 5F wedge catheter was placed through the venous sheath and was advanced to the level of the SVC. The 4F pigtail catheter was advanced to the level of the descending aorta. A full right and left heart catheterization was performed and all appropriate chambers and vessels were entered including SVC, IVC, RA, RV, MPA, LPA, LV, AAO and DAO. Oxygen saturation and pressure measurements were obtained by standard catheterization technique. After the hemodynamic data were obtained, an aortogram was performed using a 4F Pigtail catheter in the standard PA/LAT projections and the aortic valve was assessed for sized and degree of aortic valve regurgitation. The appropriate measurements made. The aortic valve measured approximately 21-mm at the annulus. Using a modified 3F pigtail catheter, the valve was crossed with an 0.018 Torque wire. This process was repeated from the LFA as well for the use of a double balloon technique. Due to the presence of a PFO, we parked Berman angiographic catheter in the LV by way of the LFV and an LV angiogram was performed. We also placed a pacing catheter in the RV via the LFV for rapid RV pacing during balloon inflation. Once double wire position was obtained across the valve, a 10 mm and 12 mmballoons were selected and advanced across the aortic valve. Inflation was then performed during rapid RV pacing until the waste on the balloons resolved. Repeat hemodynamic and angiographic data were then obtained. The catheters and sheaths were removed and hemostasis was obtained by application of local pressure. A pressure dressing was placed and Hunter was transferred to the recovery unit in stable condition. post-procedure course was unremarkable. HEMODYNAMIC DATA Pre-balloon: PSEG = 36 mmHg Post-balloon: PSEG = 9 mmHg SUMMARY successful balloon angioplast of his aortic valve. We were able to drop the gradient down to 9 mmHg without a significant change in the amount of aortic valve regurgitation. He will be observed for several hours post procedure and likely discharged later the same day. Routine follow up was recommended in 4 weeks.