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Original Question

Assign the appropriate CPT code(s) for the following diagnostic report when the insurer requires modifiers. Diagnostic Report Procedure: The patient was premedicated and brought to the cardiovascular laboratory, where the inguinal region was prepared and draped in the usual manner and local cutaneous anesthesia was obtained with 2% Xylocaine. An 8 French USCI sheath was inserted percutaneously into the right femoral artery, and 10,000 units of Heparin were given intravenously. The patient already had received 75 mg of lidocaine and 5 mg of verapamil intravenously, as well as 5 mg of Isordil sublingually. We selected an 8 French Shiley JR 4 guide catheter and positioned it in the ostium of the right coronary artery. This was a large dominant vessel. In the proximal third before a point of marked angulation, there was a 70% irregular stenosis. Further distally in the mid-right coronary artery, there was a 2-cm zone of atherosclerotic disease that was punctuated by sequential 95% and 70% narrowing. We selected an ACS micro 3.5 XT balloon catheter and were able to advance it across both lesions. However, it did require deep seating of the guide catheter with buckling it in the aortic root. We initially brought it across the lesion in the mid-right coronary artery, where the balloon was inflated a total of seven times in an overlapping manner to a maximum of seven atmospheres of pressure for a maximum duration of 90 seconds. We then withdrew the balloon to the lesion in the proximal right coronary artery and inflated it five times to a maximum of six atmospheres of pressure for a maximum duration of 45 seconds. Repeat injections following these inflations revealed wide patency at both sites. The proximal residual stenosis was less than 30%. The lesions in the mid-right coronary artery were dilated successfully to a residual of less than 30%, as well. Distal runoff was excellent. The patient tolerated the procedure quite well and no complications occurred. At this point the catheter was removed, but the femoral sheath was left in place and the patient was transferred back to her room with continuous intravenous heparin. Conclusion: Successful single-vessel, double-lesion coronary angioplasty to the proximal and mid-right coronary artery for coronary arteriosclerosis.

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