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.
Showing posts with label icd-9-cm procedures. Show all posts
Showing posts with label icd-9-cm procedures. Show all posts
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.
Subscribe to:
Comments (Atom)
