Congential or Non Congential RHC/LHC/LV/Cornonary

Okay I am a facility that performs Adult Only of Cardiac Caths. They do not even have congential codes listed on their charge sheets.

I am reviewing a case today and I am attaching doctor dictation and F/U Echo report to follow.

Patient scheduled for RHC/LHC Coronary Angiogram. No previous diagnosis of CHD

Patient underwent procedure and was found has a large left to right shunt secondary to an ASD.

RHC Completed and LHC Cath Complete in normal fashion.

Post ECHO done. Thoracic surgeon states this to be a CHD.

Now, do I code this case with CHD Codes or NON-CHD codes since there was no previous CHD diagnosis.

If CHD codes what codes would you use...

Any help would be appreciated....

Here is the long winded doctor dictation for your reading pleasure

PROCEDURES: Right and left heart cardiac catheterization complete with a

right heart cardiac catheterization and included thermodilution, cardiac

outputs, and oxygen saturations in the appropriate locations, and then

there was a big saturation run because of the detection of an

unsuspected left-to-right shunt, and then a heart cardiac

catheterization, which included left ventricular angiography and

selective native coronary angiography.

INDICATIONS: A 77-year-old male with a history of hypertension,

type 2 diabetes mellitus being treated with dietary therapy, and

recently discovered atrial fibrillation, who had an echocardiogram

showing mild to moderate aortic regurgitation, aortic sclerosis without

stenosis, mild mitral regurgitation, mild pulmonary artery systolic

hypertension with moderate tricuspid regurgitation, but initially normal

LV systolic function, who recently was detected to be in atrial

fibrillation in a nuclear stress test performed, during which he had a

limited workload of exercise, developed shortness of breath and fatigue,

had a nuclear scan that showed inferior-apical and apical hypokinesia

and ischemia with a reduced ejection fraction of 48%, who recently

developed the onset of heart failure and was placed on Lasix therapy for

diuresis and was placed on digoxin for atrial fibrillation, was already

on an ACE inhibitor, and prior to placing him on Coumadin, we performed

the right and left heart cardiac catheterization. Now, the patient had

had two prior echocardiograms performed, some of which had disparate

results. One showed normal LV systolic function. The other showed mild

LV systolic dysfunction with an ejection fraction of 51%. The patient

was brought in for right and left heart cardiac catheterization to

evaluate him for pulmonary hypertension given the heart failure, left

heart cardiac catheterization to accurately evaluate LV systolic

function and to evaluate him for significant coronary artery disease

given the positive stress test.

PREOPERATIVE DIAGNOSIS: Possible coronary disease.

POSTOPERATIVE DIAGNOSES

1. Large O2 saturation step-up suggestive of a left-to-right shunt.

2. Pulmonary hypertension.

3. Relatively controlled systemic blood pressure.

4. Cardiac output that was near normal.

5. Concentric left ventricular hypertrophy with normal left ventricular

size and overall normal systolic function.

6. Diffuse coronary disease, including distal left main, left anterior

descending, left circumflex, and right coronary artery disease, and the

disease was felt to be significant.

DESCRIPTION OF PROCEDURE: After the patient had been appropriately

prepped and draped, using a #25-gauge needle and 1% Xylocaine, the skin

overlying the right groin was anesthetized. Next, using a #22-gauge

needle, the subcutaneous tissues down to and surrounding the right

femoral vein and artery were anesthetized. Next, using a #18-gauge

single-wall needle, successful cannulation of the right femoral vein was

obtained. Once free-flowing aspiration of venous material was obtained,

a 0.035 short guidewire was inserted, and over this, a 7-French

intravenous sheath was inserted. The dilator of the sheath was removed.

The sidearm was aspirated and flushed. Next, using a #18-gauge single-

wall needle, successful cannulation of the right femoral artery was

obtained. Once free-flowing return of arterial material was obtained, a

0.035 movable core floppy J guide wire was inserted, and over this, a 6-

French intraarterial sheath was inserted. The dilator of the sheath was

removed. The sidearm was aspirated and flushed. Next, we advanced a

combination of a 6-French pigtail catheter and a 0.035 guidewire into

the right femoral artery and then into the ascending aorta. The

guidewire was removed. The catheter was aspirated and flushed. Next,

aortic pressures were obtained. Next, the pigtail catheter was left in

place while the right heart cardiac catheterization was performed, and

for the right heart cardiac catheterization, we actually eventually

advanced a 7-French thermodilution Swan-Ganz catheter. We did this twice

because of some equipment problems, and the catheter was advanced from

the right femoral vein to the common iliac vein, inferior vena cava,

right atrium, right ventricle, pulmonary artery and pulmonary capillary

wedge pressure positions under both fluoroscopic and hemodynamic

guidance. Then, the pigtail catheter, which was in the aorta, was gently

passed retrograde across the aortic valve, and left ventricular

pressures were obtained. Next, simultaneous left ventricular and

pulmonary capillary wedge pressures were obtained. Next, right heart

pullback was conducted, punctuated by oxygen saturations in the

appropriate locations, but this saturation run demonstrated abnormally

high right atrial and right ventricular saturations. Therefore, a more

thorough oxygen saturation run was performed in this patient by

obtaining a superior vena cava saturation, a high rate atrial

saturation, a mid right atrial saturation, and a right atrial

saturation, and then multiple inferior vena caval saturations, in

addition to systemic saturations. This confirmed a left-to-right shunt,

which I will get into. Once the saturation run had been completed and

the thermodilution cardiac outputs were performed while the Swan-Ganz

catheter was in the pulmonary artery, and this was done several times

because we were getting an abnormal curve from the thermodilution

cardiac outputs and the numbers would not correlate, and then we

actually exchanged out the initial Swan-Ganz catheter for a second 7-

French Swan-Ganz catheter, repeated those numbers, and used another

thermodilution machine, but later we discovered that the patient had a

huge oxygen step-up from left-to-right. Once the cardiac outputs had

been obtained and all of the oxygen saturations had been performed, a

left ventricular angiogram was performed using 25 mL of Omnipaque

contrast agent in the 30-degree RAO view, and we repeated a left

ventricular angiogram using 25 mL of Omnipaque contrast agent in the 30-

degree LAO view just to make sure that the patient did not have a

ventricular septal defect that could be detected angiographically. Once

the left ventricular angiogram had been performed, a careful left heart

pullback was conducted after the catheter was aspirated and flushed, and

then the pigtail catheter was exchanged for #4 Judkins left and #4

Judkins right coronary catheters. Once this procedure was completed, the

catheters were removed from the patient. The intraarterial and

intravenous sheaths were secured in place while we confirmed the

findings of angiography, which demonstrated diffuse coronary disease.

The patient was brought to the post-cath recovery area. He was admitted

to an observation bed on 2-East pending the review of the saturation run

and a repeat echo, which ultimately did show evidence of a large atrial

septal defect with a left-to-right shunt. He tolerated the cardiac

catheterization procedure very well, remaining hemodynamically stable

throughout the procedure. In fact, he was relaxed and slept through most

of the procedure.

HEMODYNAMICS: Mean right atrial pressure 11. Right ventricular pressure

58/1. Pulmonary artery pressure 42/9 with a mean of 22. Pulmonary

capillary wedge pressure was 11. Aortic pressure was 98/45 with a mean

of 65. Left ventricular pressure was 98/4. Post-angiographic contrast

loading, the left ventricular pressure was 118/7, and the aortic

pressure was 122/41 with a mean of 82.

OXYGEN SATURATIONS: This is where it gets very interesting. The

pulmonary capillary wedge saturation was 86%. The pulmonary artery

saturation was 81.5%. The right ventricular saturation was 82.6%, and

then repeated was 82.5%, and then repeated was 82%; we did that 3 times.

The right atrial saturation initially was 78%, then 75.7%, and 81.7%.

Therefore, we did an extensive saturation run in the atrium. He had a

superior vena cava saturation of 53.5%, a high right atrial saturation

of 54.3%, a mid right atrial saturation of 75.4%, a low right atrial

saturation of 78%, and an inferior vena caval saturation of 59.9%, with

a left ventricular saturation of 96.9%, and the average thermodilution

cardiac output was 5.34 L/min for a cardiac index, and then a repeat was

5.03 L/min for a cardiac index of 2.68 L/min per meter squared.

LEFT VENTRICULAR ANGIOGRAPHY: The left ventricular angiogram

demonstrated a left ventricle that was concentrically thickened and

normal in size and overall normal in its systolic function with a left

ventricular ejection fraction measurement of 79%, but there was an LAO

and an RAO left ventricular angiogram. It appeared to be more like 65%.

There was no significant mitral valvular prolapse and mild mitral

regurgitation.

SELECTIVE NATIVE CORONARY ANGIOGRAPHY

LEFT MAIN CORONARY ARTERY: The left main coronary artery was a

calcified, long blood vessel that gave rise to a left anterior

descending and a left circumflex coronary artery. This calcified left

main coronary artery had an ostial 10% stenosis, but the mid body of

this left main coronary artery had an area of lucency probably due to

calcification, and then the distal left main coronary artery had an

eccentric but definite stenosis of about 70% in the distal left main

coronary artery. There was TIMI grade 3 flow down it, however.

LEFT ANTERIOR DESCENDING CORONARY: The left anterior descending coronary

was a large, calcified, long blood vessel that gave rise to several

septal perforators and diagonal branches. The proximal left anterior

descending coronary had an eccentric 60% stenosis. The mid left anterior

descending coronary was diffusely diseased with stenoses of about 70% to

75%, followed by an area of pre-stenotic dilatation, followed by about a

90% stenosis that involved the origin of a diagonal branch. The distal

left anterior descending coronary had no significant stenoses, though

there was mild to moderate plaquing and calcification present. There

were no significant stenoses of the several septal perforators and

diagonal branches, save the mid level diagonal branch, which had its

origin in the 90% stenosis of the left anterior descending coronary

system.

CIRCUMFLEX SYSTEM: The left circumflex system was a moderate-sized

system that was somewhat tortuous, that was calcified, that gave rise to

a high obtuse marginal branch, which was a thin bifurcating vessel, a

distally occurring obtuse marginal branch, which was a larger vessel,

and a posterolateral branch, which bifurcated. The left main circumflex

coronary had tortuosity present with calcification with no significant

stenoses. The high obtuse marginal branch of the left circumflex system

in total, though calcified, had no high-grade stenoses with

calcification and moderate plaquing. The posterolateral portion of the

circumflex system which bifurcated had no significant stenoses. However,

there was a high thin occurring proximal obtuse marginal branch that was

subtotally occluded. There was a second obtuse marginal branch, which

bifurcated. The superior bifurcation was subtotally occluded. The

inferior bifurcation was by far a larger vessel without significant

stenoses.

RIGHT CORONARY ARTERY SYSTEM: The right coronary artery system was a

large, dominant, calcified system that gave rise to a conus artery, a

sinus nodal artery, several right ventricular branches, a posterior

descending, and a posterolateral branch. This large, dominant right

coronary was diffusely calcified. There was mild plaquing in the

proximal right coronary artery, moderate plaquing in the distal right

coronary, and then the distal right coronary artery before giving rise

to a posterolateral branch was 75% to 80% stenosed. The posterolateral

branch itself appeared to have no significant stenoses. However, the

posterior descending branch had about an 85% to 90% ostial stenosis,

followed by an area of pre-stenotic dilatation, followed by another 50%

to 60% stenosis, and this vessel was calcified.

IMPRESSION

1. Mild pulmonary artery systolic hypertension.

2. Normal pulmonary capillary wedge pressure.

3. Large oxygen step-up within the right atrium and right ventricle

suggestive of a left-to-right shunt.

4. Near normal overall cardiac output.

5. Normal pulmonary capillary wedge pressure.

6. Normal systemic blood pressure.

7. Concentric left ventricular hypertrophy with normal left ventricular

size with overall normal systolic function with mitral annular

calcification and mild mitral regurgitation.

8. Diffuse three-vessel system coronary artery disease with the

following:

a. Ostial left main coronary stenosis of 20% with the mid left main

coronary having an eccentric area of calcification with a 50% to 60%

stenosis, and then the distal left main circumflex coronary artery with

about a 70% stenosis.

b. Left anterior descending coronary was diffusely calcified and

diseased with the mid vessel having sequential 75% to 80% and then 90%

stenoses with the second portion of the stenoses involving the origin of

a diagonal branch.

c. Left circumflex system with calcification with a subtotally occluded

small, thin, short obtuse marginal branch, and then a second obtuse

marginal branch to the superior bifurcation was subtotally occluded. The

inferior bifurcation was widely patent. The posterolateral branch was

widely patent, without significant stenoses.

d. Large, dominant right coronary artery, which has diffuse disease

highlighted by a posterior descending branch ostial stenosis of about

85% to 90%.

9. A large left-to-right shunt with a Qp/Qs of 2.67/1. Because of that

large shunt, we obtained a repeat echocardiogram here in the

catheterization lab holding area. The patient has a large atrial septal

defect.

IMPRESSION

1. Pulmonary hypertension.

2. Relatively controlled systemic blood pressure.

3. Near normal cardiac output.

4. Large left-to-right shunt secondary to an atrial septal defect.

5. Three-vessel system coronary artery disease.

6. Concentric left ventricular hypertrophy with normal left ventricular

size and overall normal systolic function with mitral annular

calcification and mild mitral regurgitation, but there is three-vessel

system coronary artery disease, including left main disease.

PLAN: A Cardiothoracic Surgical consultation will be obtained with

respect to the patient having coronary artery bypass graft surgery and

an atrial septal defect repair.

The thoracic surgeon notes in his consult after the cath and then echo was done : "An echocardiogram demonstrated a large left-

right shunt, hence an atrial septal defect that was diagnosed which is

congenital from birth. However, there is no Eisenmenger physiology

noted."

Congential or Non Congential RHC/LHC/LV/Cornonary