# documention for 93306



## nowings1224 (Aug 4, 2009)

Does somebody have a sample note for procedure code 93306. One of my doctors that I do billing for has horrible notes. I am trying to help him.
Thanks,
Nancy


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## jlb102780 (Aug 11, 2009)

This is how one of my doctors dictates:

INDICATION                                                                    
CHF.  Mitral valve replacement.  Pulmonary hypertension.                      

INTERPRETATION:                                                               
2D and M-Mode evaluation of the cardiac chambers were obtained.  Left        
ventricular end diastolic and systolic dimensions reveal significantly        
enlarged left ventricle.  Contractility is preserved with ejection fraction   
at about 55%.  Left atrium appears to be enlarged.  By history, the patient   
has a prosthetic mitral valve.  There are sclerotic changes noted in the      
mitral annulus.  There is also sclerosis noted of the aortic valve.  The      
mitral valve appears to be seated well.                                       

Doppler and color flow evaluation of the valves revealed mild aortic          
insufficiency with aortic pressure half time at 930 meters per second.  There 
is moderate tricuspid regurgitation with estimated right ventricular systolic 
pressure of 43 mmHg.  There is prosthetic mitral valve functioning well with  
a trivial mitral regurgitation noted, probably appropriate for the valve.     

                           MEASUREMENTS -                                     
             M-MODE                   DOPPLER -                               
             NORMAL               NORMAL   LOCATION VELOCITY                  
LVIDD 6.5    <5.6   LA     4.7                                                
LVIDS 4.5    <3.5   AO     2.8    2.0-3.8                                     
IVSD  1.1    <1.2   ACS                                                       
IVSS  1.3           LVOT                                                      
LVPWD 1.2    <1.2   EF     57%    Teicholz                                    
LVPWS 1.9           FS                                                        
RV           <2.6   HR                                                        

CONCLUSOIN                                                                    
Dilated left with a prosthetic mitral valve with preserved left ventricular   
function, left atrial enlargement, trivial mitral regurgitation, mild aortic  
insufficiency and moderate tricuspid regurgitation, pulmonary hypertension.   

Jammie, CPC


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