# Tee - I am new with billing



## lindseyj (Dec 31, 2008)

I am new with billing out TEE can someone help me with which Code this would be
Thank you
Lindsey



TRANSESOPHAGEAL ECHOCARDIOGRAM

 INDICATIONS: This is an 80-year-old Caucasian female who presented with
 elevated temperature as well as elevated white count and with mental status
 changes. She is being evaluated for possible endocarditis.

 MEDICATION USED: IV Versed, IV Fentanyl.

 VITAL SIGNS: Both pre and post were within normal limits.

 PROCEDURE: After explaining the risks, benefits, and alternatives of the
 procedure to the patient in detail and answering all questions to
 satisfaction, an informed consent was obtained in writing. The patient denied
 having eaten food in the past six hours. The patient denied any dysphagia or
 odynophagia. The patient denied any loose teeth. The patient was then
 connected to continuous pulse oximetry, automated blood pressure monitor and
 electrocardiographic monitoring. Oxygen was administered by nasal canula
 continuously. The patient was placed in the full upright position and the
 posterior oropharynx was anesthetized with Cetacaine spray and viscous
 lidocaine. Once complete suppression of the gag reflex was obtained, the
 patient was then placed in the left lateral decubitus position. The neck was
 flexed, and bite block was placed in the patient's mouth. Sedation was
 administered intravenously. Once adequate sedation was achieved, a
 well-lubricated ante-flex TTE multipoint intraesophageal echocardiographic
 probe was inserted into the midline posterior oropharynx under digital
 guidance. General pressure was applied as the patient swallowed and the
 esophagus was intubated without difficulty. The scope was advanced to the
 level of gastric fundus without encountering resistance. Multipoint images of
 various cardiac structures were obtained from transesophageal views. The
 intra-atrial septum was assessed by application of color-flow Doppler as well
 as agitated saline. The scope was then rotated approximately 180 degrees and
 withdrawn, visualizing the length of the aorta including the arch. The scope
 was the slowly withdrawn as the patient was continually suctioned. The
 patient tolerated the procedure well with no foreseen complications.

 The patient tolerated the procedure well without any foreseen complication
 and was then transferred back to the patient's room in stable and
 satisfactory condition.

 SUMMARY OF FINDINGS:

 MITRAL VALVE: The mitral valve leaflet demonstrated mild to moderate mitral
 valve regurgitation secondary to mitral valve leaflet prolapse. Blood
 pressure was 145/55. There was no significant evidence of mass, thrombus, or
 vegetation noted.

 AORTIC VALVE: The aortic valve demonstrated trileaflet aortic valve with
 sclerotic trileaflet aortic valve. Noncoronary cause was noted with


 heterogenous soft tissue density suggestive of possible of endocarditis versus
 fibroelastoma. There was also tissue density noted on the aortic surface,
 which was mobile in nature and this was more of a soft tissue density. It did
 have some mobility as well as very circumferential heterogenous density and
 noncoronary cause with echo lucency noted as well. There was trace aortic
 insufficiency noted.

 DIMENSIONS: The aortic annulus measured 2.31 cm, sinus at 3.0 cm, and the
 sinus tubular junction 2.47 cm and the proximal roots measured 2.60 cm.

 LEFT ATRIUM: The left atrium was anatomically normal in size and function
 with no significant evidence of mass, thrombus or spontaneous echo contrast.

 LEFT ATRIAL APPENDAGE: The left atrial appendage was anatomically normal in
 structure and function with no significant evidence of mass, thrombus or
 spontaneous echo contrast. The inferior velocity was 0.53 meters/second and
 outflow velocity 0.5 meters/second.

 TRICUSPID VALVE: The tricuspid valve was anatomically normal in structure.
 There was trace tricuspid regurgitation noted. There was no significant
 evidence of mass, vegetation or thrombus noted. The pacemaker wire was noted
 transversely in the tricuspid valve which was intact with no vegetation noted
 and no echodensity noted on the tricuspid valve. The pacemaker lead was well
 visualized transversing from the superior vena cava through the right atrium
 into the right ventricle. There was also noted too, pacemaker lead 1 going to
 the right atrial appendage as well as one going through the tricuspid valve
 into the left ventricle. No ROVSP were obtained.

 INTRAATRIAL SEPTUM: The intraatrial septum was intact without any significant
 evidence of left to right shunt, no right to left shunt by color-flow as well
 as agitated saline study.


 LEFT VENTRICLE: The left ventricle was anatomically normal in size and
 function with no significant evidence of mass, thrombus or spontaneous echo
 contrast noted. Ejection fraction was approximately greater than 60%.

 AORTA: The aorta demonstrated mild to moderate heterogeneous plaquing
 throughout the aorta. There was no significant evidence of aneurysm, no
 dissection or dilatation.

 PULMONARY VALVE: The pulmonary valve was anatomically normal in structure and
 function with no significant evidence of mass, thrombus or vegetation. The
 annulus measured 1.97 cm.

 RIGHT VENTRICLE: The right ventricle was anatomically normal in size and
 function with no significant evidence of mass, thrombus or spontaneous echo
 contrast noted.

 PULMONARY ARTERY: The pulmonary arteries were anatomically normal in size and
 structure and was well visualized up to the level of the bifurcation with no
 significant evidence of thrombus or vegetation or pulmonary embolism.

 RIGHT ATRIUM: The right atrium was anatomically normal in size and function
 with no significant evidence of mass, thrombus or spontaneous echo contrast
 noted.



 PULMONARY VEINS: Pulmonary veins were not well visualized.

 IMPRESSION:
    1.     Heterogenous soft tissue echo density noted on the noncoronary cause as
           well as a mobile density noted on the aortic surface of the aortic valve
           suggestive of vegetation versus Lambl excrescence vs  possible
           fibroelastoma. But in regards to this patient presenting with
           elevated temperature as well as elevated white count with no source
           of infection, I do have a very high clinical suspicion for
           vegetation as well as the soft tissue density does have a
           heterogenity in nature, which is more suspicious for vegetation
           suggestive of endocarditis.
    2.     Preserved left ventricular function.
    3.     Mild to moderate mitral regurgitation with posterior mitral valve
           leaflet prolapse noted.
    4.     Pacemaker wires noted without any significant vegetation or
           thrombus noted.
    5.     No significant evidence of left to right shunt or atrial septal
           defect noted.
    6.     Sclerotic trileaflet aortic valve.

 RECOMMENDATIONS:
 I do recommend this patient to be treated for endocarditis with antibiotics
 for the next four to six weeks. At which point, a repeat Transesophageal echo
 needs to be performed to evaluate for this heterogenous echo density soft
 tissue mass.

 We will continue to follow this patient inpatient as well as outpatient. The
 case was discussed with primary care physician as well as ordering physician.


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## jewlz0879 (Jan 2, 2009)

TEE 93312 
Doppler 93320
Doppler Color-flow 93325

If was done in hosp add mod -26

Hope that helps

Julie D. CPC


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