This patient transferred from hospital A with acute anterior myocardial infarction to hospital B. Patient received left heart catheterization, coronary angiogram using jl5 and jr4 catheters, and left ventriculogram, which revealed three vessel coronary artery disease and an emergent 3 vessel coronary artery bypass grafting was performed, on cardiopulmonary bypass; left internal mammary artery graft to the left anterior descending artery and saphenous vein graft from the aorta to the diagonal artery and from the aorta to the left posterior descending artery.
Tuesday, May 24, 2011
Saturday, April 23, 2011
Code this Cardiac Catheterization Report
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.
Basic ICD-9-CM Coding Quiz
Answer the following questions by using ICD-9-CM diagnosis codes.
- Sickle cell anemia with crisis
- Psychogenic paroxysmal tachycardia
- Alzheimer’s disease with dementia
- Hypertensive kidney disease, CHF and acute systolic heart failure.
- Aspiration pneumonia with pneumonia due to staphylococcus aureus. Patient also has emphysema.
Answers: 1) 282.62. 2) 316, 427.2, 3) 331.0, 294.10. 4) 403.90, 585.9, 428.0, 428.21. 5)507.0, 482.21, 492.8.
Saturday, March 5, 2011
Pregnancy Coding Examples
Case #1: A 35-yr-old is admitted at 38 3/7 weeks in active labor. History: Gestational DM, on insulin, history of hyperemesis in 1st trimester, resolved. Pt has bicornuate uterus, with fetus in right side.
Hospital Course: After 2 hours a vaginal exam is performed showing little progress, only at 3 cm, due to irregular and weak contractions. Pitocin augmentation is given per protocol. An IUPC is inserted after administration of epidural. Pt rechecked several hours later, fetal head is still at -2, failure to descend. Pt taken to OR for LTCS, delivery of a viable male infant. On POD #2, pt noted to be hemorrhaging blood. Is returned to OR for exploration. Site is reopened, with retained POC found and removed. Two units PRBCs given.
Case# 2. A 38-yr-old primigravida is admitted at 42 1/7 weeks gestation for repeat induction of labor with Pitocin. Pt is Somalian, status post female circumcision with infibulation. Medications on admit: Xanax for anxiety disorder, atenolol for chronic HTN. Pt progressed to full dilation in 5 hours, taken to delivery suite. Consent obtained for anterior episiotomy with approval to leave open. Pt had precipitous 2nd stage with delivery of a viable female infant. Nuchal cord x 1. Examination revealed high vaginal laceration, repaired. Coccygeal fracture noted on 1st PP day, due to fetal head during delivery.
Case #3: 26-yr-old primigravida with history of genital herpes (last outbreak 3 years ago, not on antiviral therapy), hypothyroidism on replacement therapy, s/p bariatric surgery, and s/p cervical conization 2 yrs prior to admission is now admitted in active labor. After 3 hrs a vaginal exam reveals presentation of fetal face and hand. Midline episiotomy performed. Maternal pushing efforts not effective, felt due to shoulder dystocia. McRoberts maneuver and suprapubic pressure applied with resolution of dystocia. Delivery of a viable female infant. Perineum examined, showing extension of episiotomy, repaired. After 1 hour post-delivery, placenta shows no sign of release from uterus. Manually extracted.
Answers:
Case #1: Principal Diagnosis: 652.51
Secondary Diagnoses: 648.81, 654.01, 653.11, 666.22, V27.0, V58.67
Procedures: 74.1, 99.04.
Case #2: Principal Diagnosis: 645.21
Secondary diagnoses: 665.41, 663.21, 665.61, 661.31, 642.01, 648.41, 300.00, V27.0
Procedures: 73.59, 73.6, 73.4, 75.69
Case #3: Principal Diagnosis: 660.41
Secondary Diagnoses: 652.41, ?652.7/81 for hand, 664.11, 654.61, 648.11, 244.9, 649.21, V12.09, V27.0
Procedures: 73.59, 73.6, 75.69, 75.4
Note: Answers are author's views. Please refer to the ICD-9-CM for answers.
Common Pediatric Vaccination V codes
| ICD-9-CM | VACCINE NAME | BRAND NAME | ||
| V03.81 | Hemophilus influenza B vaccine (Hib) | HibTITER | ||
| V03.81 | Hemophilus influenza B vaccine (Hib) | PedvaxHIB | ||
| V03.81 | Hemophilus influenza B vaccine (Hib) | ActHIB | ||
| V03.81 | Hemophilus influenza B vaccine (Hib) | HIEBERIX | ||
| V03.82 | Pneumococcal vaccine | PNEUMOVAX 23 | ||
| V03.89 | Meningococal vaccine | Menomune | ||
| V03.89 | Meningococal vaccine | Menactra | ||
| V03.89 | Meningococal vaccine | Menveo | ||
| V04.81 | Influenza virus vaccine | Fluzone | ||
| V04.81 | Influenza virus vaccine | Fluvirin | ||
| V04.81 | Influenza virus vaccine | FLUARIX | ||
| V04.81 | Influenza virus vaccine | FluMist | ||
| V04.89 | Human Papilloma virus vaccine (HPV) | GARDASIL | ||
| V04.89 | Human Papilloma virus vaccine (HPV) | CERVARIX | ||
| V04.89 | Rotavirus vaccine | RotaTeq | ||
| V04.89 | Rotavirus vaccine | ROTARIX | ||
| V05.3 | Hepatitis A vaccine | HAVRIX | ||
| V05.3 | Hepatitis A vaccine | VAQTA | ||
| V05.3 | Hepatitis B vaccine | RECOMBIVAX HB | ||
| V05.3 | Hepatitis B vaccine | ENERGIX-B | ||
| V05.4 | Varicella vaccine | VARIVAX | ||
| V06.1 | Diphtheria, tetanus toxoids, and acellular pertusis vaccine (DTaP) | DAPTACEL | ||
| V06.1 | Diphtheria, tetanus toxoids, and acellular pertusis vaccine (DTaP) | Tripedia | ||
| V06.1 | Diphtheria, tetanus toxoids, and acellular pertusis vaccine (DTaP) | INFANRIX | ||
| V06.1 | Diphtheria, tetanus toxoids, and acellular pertusis vaccine (DTaP) | ADACEL | ||
| V06.1 | Diphtheria, tetanus toxoids, and acellular pertusis vaccine (DTaP) | BOOSTRIX | ||
| V06.4 | Measles, mumps, rubella virus vaccine (MMR) | M-M-R II | ||
| V06.5 | Tetanus and Diptheria toxoids (Td) | DECAVAC | ||
| V06.8 | Measles, mumps, rubella and varicella vaccine (MMRV) | ProQuad | ||
| V06.8 | DTaP-Hib | TriHiBit | ||
| V06.8 | DTap-Hep B-IPV | PEDIARIX | ||
| V06.8 | Hepatitis B and Hib (Hep B-Hib) | COMVAX | ||
| V06.8 | MenCY-Hib | MenHibrix | ||
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