Heart Catheterization, Ventriculography, & Angiography
Description: Left heart catheterization with ventriculography, selective coronary angiography. Standard Judkins, right groin. Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.
(Medical Transcription Sample Report)
NAME OF PROCEDURE: Left heart catheterization with ventriculography, selective coronary angiography.
INDICATIONS: Acute coronary syndrome.
TECHNIQUE OF PROCEDURE: Standard Judkins, right groin. Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.
ANTICOAGULATION: The patient was on heparin at the time.
COMPLICATIONS: None.
I reviewed with the patient the pros, cons, alternatives, risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of a cardiac chamber, dissection of an artery requiring countershock, infection, bleeding, ATN allergy, need for cardiac surgery. All questions were answered, and the patient desired to proceed.
HEMODYNAMIC DATA: Aortic pressure was in the physiologic range. No significant gradient across the aortic valve.
ANGIOGRAPHIC DATA
1. Ventriculogram: The left ventricle is of normal size and shape, normal wall motion, normal ejection fraction.
2. Right coronary artery: Dominant. Nonobstructive disease in the system.
3. Left coronary: Left main, left anterior descending and circumflex systems showed no significant disease.
CONCLUSIONS
1. Normal left ventricular systolic function.
2. Nonobstructive coronary artery disease.
PLAN: Based upon this study, medical therapy is warranted. Six-French Angio-Seal was used in the groin.
Answers:
Code: Dx: 414.01, 411.1
CPT: 93458
ICD Px: 37.22, 88.56, 88.53
Note: Answers are blogger's views. Please refer to ICD-9-CM and CPT for correct information. Sample is taken from MTsamples.
Description: Left heart catheterization with ventriculography, selective coronary angiography. Standard Judkins, right groin. Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.
(Medical Transcription Sample Report)
NAME OF PROCEDURE: Left heart catheterization with ventriculography, selective coronary angiography.
INDICATIONS: Acute coronary syndrome.
TECHNIQUE OF PROCEDURE: Standard Judkins, right groin. Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.
ANTICOAGULATION: The patient was on heparin at the time.
COMPLICATIONS: None.
I reviewed with the patient the pros, cons, alternatives, risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of a cardiac chamber, dissection of an artery requiring countershock, infection, bleeding, ATN allergy, need for cardiac surgery. All questions were answered, and the patient desired to proceed.
HEMODYNAMIC DATA: Aortic pressure was in the physiologic range. No significant gradient across the aortic valve.
ANGIOGRAPHIC DATA
1. Ventriculogram: The left ventricle is of normal size and shape, normal wall motion, normal ejection fraction.
2. Right coronary artery: Dominant. Nonobstructive disease in the system.
3. Left coronary: Left main, left anterior descending and circumflex systems showed no significant disease.
CONCLUSIONS
1. Normal left ventricular systolic function.
2. Nonobstructive coronary artery disease.
PLAN: Based upon this study, medical therapy is warranted. Six-French Angio-Seal was used in the groin.
Answers:
Code: Dx: 414.01, 411.1
CPT: 93458
ICD Px: 37.22, 88.56, 88.53
Note: Answers are blogger's views. Please refer to ICD-9-CM and CPT for correct information. Sample is taken from MTsamples.
414.01 would be the correct code as there in no indication that the pt has ever had a bypass.
ReplyDeleteQuestion:
A patient is admitted with angina and has known CAD. Patient has no previous history of any procedures being done. What code(s) should be assigned?
Note from 3M:
For additional information regarding the sequencing of CAD with unstable angina refer to Coding Clinic, Third Quarter, 2001, pg 15
Answer:
Assign code 414.01, Coronary atherosclerosis, of native coronary artery, for a patient with angina and an established diagnosis of coronary artery disease. Assign code 413.9, Other and unspecified angina pectoris, as an additional diagnosis. This answer is consistent with information previously published in Second Quarter 1994 Coding Clinic, page 15.
thank you..made the correction
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