As part of the new coding format for our newsletter, RT Welter is excited to offer you a new surgery coding series in which we want to help you! The 2nd week of every month we will highlight a complicated surgical case. This week we are highlighting a general surgery case. We want to hear from you! If you have a complicated surgery case and need help with coding, please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. RT Welter will not use any medical records submitted in which PHI is not removed and protected. Click Here To Submit Redacted Surgery Case Study
Procedure: Left heart catheterization with selective coronary angiography and ventriculogram.
Indications: 73-year-old woman with a history of hypertension who presents with acute chest pain and who was found to have an abnormal stress test.
- Hemodynamics: Left ventricular pressure as well as aortic root pressure were normal with mildly elevated left ventricular end-diagnostic filling pressure. No specific gradient was seen across the aortic valve suggesting aortic stenosis.
- Ventriculogram: In the right anterior oblique view ventriculogram was performed and demonstrated normal ventricular systolic function of 60% with no segmental wall motion abnormalities. No significant mitral regurgitation was appreciated.
- Coronary anatomy: The left main gave rise to the left anterior descending artery and left circumflex branch. The left main was free of any significant disease.
- The left anterior descending artery was a good size vessel that wrapped around the apex and gave off several septal perforators, as well as three diagonal branches. Diagonal 2 was a larger vessel and the LAD as well as the diagonal branches had a small contour and no high grade obtrusive lesions were appreciated.
- The left circumflex is a large nondominant vessel which terminates within the AV groove and gives off a left posterolateral branch. The left circumflex gave off two obtuse marginal branch the larger vessel. The contour of this vessel and its branches were smooth and no high grade obstructive lesions were appreciated.
- The right coronary artery was a large and dominant vessel which gave off an acute marginal branch and terminated as a right posterolateral and right posterolateral branch. The contour of this vessel was smooth and no high grade obstructive lesions were appreciated.
Correct CPT and ICD-10 Codes:
93458 -26 Modifier = 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
R94.39 – Abnormal result of other cardiovascular function study
R07.9 – Chest pain, unspecified
I10 – Essential (primary) hypertension