amym
Guest
I have not done cardiology coding in a bit now. Is it appropriaate to code this as 93454-26?
SUMMARY:
-- CORONARY CIRCULATION:
-- Distal RCA: There was a tubular 50 % stenosis in the distal third of
the vessel segment. The lesion was hazy, ulcerated, and was associated
with a small filling defect consistent with thrombus. There was TIMI grade
2 flow through the vessel (partial perfusion). This lesion is a likely
culprit for the patient's recent myocardial infarction. -- Right
posterolateral segment: There was a diffuse 70 % stenosis. The lesion was
ulcerated, complex, and was associated with a moderate filling defect
consistent with thrombus. This lesion is a likely culprit for the
patient's recent myocardial infarction.
-- CARDIAC STRUCTURES:
-- EF was not assessed.
PROCEDURES PERFORMED:
-- Right coronary angiography.
-- Left coronary angiography.
RECOMMENDATIONS:
Vessel and branch highly tortuous- Will start Integrilln drip and bring
for re-evaluation.
INDICATIONS: Angina/MI: myocardial infarction without ST elevation
(NSTEMI).
VENTRICLES: EF was not assessed.
CORONARY VESSELS: The coronary circulation is right dominant. Ostial left
main: Normal. Proximal left main: Normal. Mid left main: Normal. Distal
left main: Normal. Proximal LAD: Normal. Mid LAD: Normal. Distal LAD:
Normal. Proximal circumflex: Normal. Mid circumflex: Normal. Distal
circumflex: Normal. Proximal RCA: Normal. Mid RCA: Normal. Distal RCA:
There was a tubular 50 % stenosis in the distal third of the vessel
segment. The lesion was hazy, ulcerated, and was associated with a small
filling defect consistent with thrombus. There was TIMI grade 2 flow
through the vessel (partial perfusion). This lesion is a likely culprit
for the patient's recent myocardial infarction. Right posterolateral
segment: There was a diffuse 70 % stenosis. The lesion was ulcerated,
complex, and was associated with a moderate filling defect consistent with
thrombus. This lesion is a likely culprit for the patient's recent
myocardial infarction.
PROCEDURE: The risks and alternatives of the procedures and conscious
sedation were explained to the patient and informed consent was obtained.
The patient was brought to the cath lab and placed on the table. The
planned puncture sites were prepped and draped in the usual sterile
fashion. Oxygen 2 L/min.
-- Right radial artery access. The puncture site was infiltrated with
local anesthetic. The vessel was accessed using the modified Seldinger
technique, a wire was threaded into the vessel, and a catheter was
advanced over the wire into the vessel.
-- Right coronary artery angiography. A catheter was advanced to the
aorta and positioned in the vessel ostium under fluoroscopic guidance.
Angiography was performed in multiple projections using hand-injection of
contrast.
-- Left coronary artery angiography. A catheter was advanced to the aorta
and positioned in the vessel ostium under fluoroscopic guidance.
Angiography was performed in multiple projections using hand-injection of
contrast.
SUMMARY:
-- CORONARY CIRCULATION:
-- Distal RCA: There was a tubular 50 % stenosis in the distal third of
the vessel segment. The lesion was hazy, ulcerated, and was associated
with a small filling defect consistent with thrombus. There was TIMI grade
2 flow through the vessel (partial perfusion). This lesion is a likely
culprit for the patient's recent myocardial infarction. -- Right
posterolateral segment: There was a diffuse 70 % stenosis. The lesion was
ulcerated, complex, and was associated with a moderate filling defect
consistent with thrombus. This lesion is a likely culprit for the
patient's recent myocardial infarction.
-- CARDIAC STRUCTURES:
-- EF was not assessed.
PROCEDURES PERFORMED:
-- Right coronary angiography.
-- Left coronary angiography.
RECOMMENDATIONS:
Vessel and branch highly tortuous- Will start Integrilln drip and bring
for re-evaluation.
INDICATIONS: Angina/MI: myocardial infarction without ST elevation
(NSTEMI).
VENTRICLES: EF was not assessed.
CORONARY VESSELS: The coronary circulation is right dominant. Ostial left
main: Normal. Proximal left main: Normal. Mid left main: Normal. Distal
left main: Normal. Proximal LAD: Normal. Mid LAD: Normal. Distal LAD:
Normal. Proximal circumflex: Normal. Mid circumflex: Normal. Distal
circumflex: Normal. Proximal RCA: Normal. Mid RCA: Normal. Distal RCA:
There was a tubular 50 % stenosis in the distal third of the vessel
segment. The lesion was hazy, ulcerated, and was associated with a small
filling defect consistent with thrombus. There was TIMI grade 2 flow
through the vessel (partial perfusion). This lesion is a likely culprit
for the patient's recent myocardial infarction. Right posterolateral
segment: There was a diffuse 70 % stenosis. The lesion was ulcerated,
complex, and was associated with a moderate filling defect consistent with
thrombus. This lesion is a likely culprit for the patient's recent
myocardial infarction.
PROCEDURE: The risks and alternatives of the procedures and conscious
sedation were explained to the patient and informed consent was obtained.
The patient was brought to the cath lab and placed on the table. The
planned puncture sites were prepped and draped in the usual sterile
fashion. Oxygen 2 L/min.
-- Right radial artery access. The puncture site was infiltrated with
local anesthetic. The vessel was accessed using the modified Seldinger
technique, a wire was threaded into the vessel, and a catheter was
advanced over the wire into the vessel.
-- Right coronary artery angiography. A catheter was advanced to the
aorta and positioned in the vessel ostium under fluoroscopic guidance.
Angiography was performed in multiple projections using hand-injection of
contrast.
-- Left coronary artery angiography. A catheter was advanced to the aorta
and positioned in the vessel ostium under fluoroscopic guidance.
Angiography was performed in multiple projections using hand-injection of
contrast.