# pericardial effusion



## CodeProAl (Oct 20, 2016)

Date of procedure: 9.10.16

The patient has a pericardial effusion. This is approximately 2 to 2.4 cm along the inferior surface of the left ventricle, it does not extend up around the right ventricular anterior wall more than 0.2 cm. There is no involvement of the right atrium or the right ventricle with volume chain. The volumes in the right atrium and the right ventricle are normal. There is normal increased right sided velocities with inspiration decreased with expiration. The patient has no tamponade physiology. There is severe concentric left ventricular hypertrophy present with thickness of 11 and 13 mm to the septum and posterior wall. There is severe left atrial enlargement present at 5.6cm tricuspid regurgitation. it is 1-2+ with right sided pressure of 73mm which is pulmonary hypertension. There is a 3 leaflet aortic valve present with aortic valve leaflet sclerosis. There is 1+ aortic regurgitation. No aortic stenosis present. Mitral regurgitation 1+ left ventricular ejection fraction is 72%. The left ventricular filling pressures upper limits of normal. 

Overall, the patient does have a pericardial effusion, but there is no tamponade physiology present. 

Can anyone assist me with where to start in finding the CPT code to bill?  I am at a loss as to where to begin with what has been documented. Any help appreciated!!

Thank you.


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## AmandaBriggs (Oct 24, 2016)

CodeProAl said:


> Date of procedure: 9.10.16
> 
> The patient has a pericardial effusion. This is approximately 2 to 2.4 cm along the inferior surface of the left ventricle, it does not extend up around the right ventricular anterior wall more than 0.2 cm. There is no involvement of the right atrium or the right ventricle with volume chain. The volumes in the right atrium and the right ventricle are normal. There is normal increased right sided velocities with inspiration decreased with expiration. The patient has no tamponade physiology. There is severe concentric left ventricular hypertrophy present with thickness of 11 and 13 mm to the septum and posterior wall. There is severe left atrial enlargement present at 5.6cm tricuspid regurgitation. it is 1-2+ with right sided pressure of 73mm which is pulmonary hypertension. There is a 3 leaflet aortic valve present with aortic valve leaflet sclerosis. There is 1+ aortic regurgitation. No aortic stenosis present. Mitral regurgitation 1+ left ventricular ejection fraction is 72%. The left ventricular filling pressures upper limits of normal.
> 
> ...




This appears to me to be an echocardiogram report.  It is missing mention a few of the required structures in order to bill the complete code, 93306 - namely the tricuspid valve, the pericardium and adjacent portions of the aorta.  I would suggest coding with 93308, 93321 and 93325.  You may need to use Modifier 26 on these codes if it was done in the facility setting.


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