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.
