Ask Dr. Z

I am having trouble coding one of our physician's dictation. He is trying to bill a left and right heart catheterization as well as left and right congenital heart catheterization. Is that possible?  He wants to bill the following: 93460-26, 93531-26, 93463, 93464-26, 93567, 93568.  Would this be appropriate?

CARDIAC CATHETERIZATION INDICATION FOR STUDY: Evaluation of hemodynamic significance of patent ductus arteriosus. FINAL IMPRESSION: 1. Angiographic confirmation of a 3.8 mm diameter patent ductus arteriosus with an associated QP:QS shunt fraction of 1.25. 2. Mild pulmonary hypertension. 3. Elevated left ventricular end-diastolic pressure. 4. Widened pulse pressures secondary to patent ductus arteriosus. 5. Normal pulmonary vascular resistance and pulmonary vascular resistance index and transpulmonary gradient. 6. Normal coronary anatomy. DISCUSSION: The hemodynamic significance of the patient's patent ductus arteriosus is likely a modest contributor to the patient's exercise intolerance and recent heart failure admission. Her QP:QS is likely underestimated as a definitive sample distal to pulmonary flow was difficult to ascertain, but was confirmed as best as possible via angiographic method using a JR4 catheter. Her other contributors to exercise intolerance include obstructive lung disease, the etiology of which is yet to be elucidated, particularly given her abcense of smoking history. Alpha 1-Anti trypsin serology is pending. Formal pulmonology consultation has been undertaken and her high resolution CT scan today evidences air trapping of unclear etiology. Consideration may be given to coiling of her patent ductus arteriosus or the usage of an Amplatz occluder. Formal consultation with pediatric cardiology at XX Hospital may be considered. PROCEDURE: Risks and benefits were explained to the patient. The patient was brought to the catheterization lab in a resting fasting state. The right femoral artery and vein were chosen for vascular access. JL4 JR4 catheters were used for selective angiography. Pigtail catheter was used for aortic angiography. A JR4 catheter was used for pulmonary arterial angiography. At the conclusion of the procedure, a StarClose device was deployed for hemostasis. No immediate complications were noted. CARDIAC CATHETERIZATION DATA: 1. Weight 56.7 kg. 2. Body surface area 1.56. 3. Blood pressure 109/41 with a mean of 60. 4. Oxygen consumption directly measured outside the catheterization lab was 208 mL per minute. 5. Respiratory quotient 0.78. 6. RA pressure, 8/60 (4). 7. RV 36/1, 7. 8. PA 26/ 3 (15). 9. With exercise, mean PA pressure was 20/8 with mean of 13. 10. Wedge pressure was 10/9 (7). 11. Aortic pressure 118/50, mean of 76. 12. LV pressure process 125/4, 19. 13. Saturations in the aorta were 96%. 14. PA saturation was 76%. 15. Pulmonary capillary wedge saturation was 92%. 16. Right ventricular saturation was 73%. 17. Right atrial saturation 64%. 18. Superior vena cava saturation 69%. 19. Inferior vena cava saturation 74%. 20. Attempts to cannulate patent ductus arteriosus, either from the pulmonary or arterial circuit were unsuccessful using a JR4 and IMA catheter. Wires including a BMW wire and Versa Core wire. Selective angiography of the pulmonary arterial tree did not evidence a communication with the aorta likely secondary to increased aortic pressures relative to pulmonary artery pressure; however, communication was identified from the arterial circuit to the main pulmonary artery in the LAO 60 degree position. 21. Hemoglobin 10.5. 22. Heart rate 65. 23 QP:QS 1.25. 24. Cardiac output and index by the Fick method were 6.12 and 3.92 respectively. 25. AVO2 difference 3.4. 26. Transpulmonary gradient 8. 27. Pulmonary vascular resistance 1.3. 28. Pulmonary vascular resistance index 2.04. 29. Right ventricular stroke work index 663. 30. Aortic root angiography demonstrated a 3.8 mm ostial diameter of a patent ductus arteriosus. The maximal luminal diameter of the ascending aorta was 34.9 mm. 31. Pulmonary artery angiography did not evidence a communication to the aortic circuit. CORONARY ANATOMY: Left main arose from the left coronary cusp, bifurcated into the left anterior descending and left circumflex coronary arteries, and left circumflex was dominant. The right coronary was nondominant and arose from the right coronary cusp. COMPLICATIONS: None. FLUOROSCOPY TIME: 30.9 minutes. TOTAL CONTRAST ADMINISTERED: 180 mL.