amym
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Can I bill for 93454 and 93571?
INDICATIONS: Pt brought here for planned PCI of Ramus and FFR of moderate LAD lesion Coronary artery disease: significant (50% or greater) lesion in a major coronary artery.
PRIOR DIAGNOSTIC TEST RESULTS: Nuclear stress test was positive. There was ischemia in the territory of the circumflex.
CORONARY VESSELS: Left main: Normal. LAD: There was a 50 % stenosis in the middle third of the vessel segment. 1st diagonal: There was a 50 % stenosis. Circumflex: There was a 0 % stenosis at the site of a prior stent, in the distal third of the vessel segment. Ramus intermedius: There was a 100 % stenosis. There was TIMI grade 1 flow through the vessel (slow flow without perfusion). This lesion is a chronic total occlusion.
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.
-- Right femoral 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 sheath was advanced over the wire into the vessel.
-- 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.
-- ULTRASOUND OF VESSEL..
Test started at 09:15. Test concluded at 10:27. RADIATION EXPOSURE:
Fluoroscopy time: 19.4 min.
CONTRAST GIVEN:
Omnipaque 70 ml.
Angiographic findings
Native coronary lesions:
7LAD: Lesion 1: 50 % stenosis.
7D1: Lesion 1: 50 % stenosis.
7Circumflex: Lesion 1: 0 % stenosis, site of prior stent.
7Ramus intermedius: Lesion 1: 100 % stenosis.
HEMODYNAMIC TABLES
Pressures: Baseline
Pressures: - HR: 84
Pressures: - Rhythm:
Pressures: -- Aortic Pressure (S/D/M): 191/137/158
Outputs: Baseline
Outputs: -- CALCULATIONS: Age in years: 65.41
Outputs: -- CALCULATIONS: Body Surface Area: 2.09
Outputs: -- CALCULATIONS: Height in cm: 175.00
Outputs: -- CALCULATIONS: Sex: Male
Outputs: -- CALCULATIONS: Weight in kg: 93.40
INDICATIONS: Pt brought here for planned PCI of Ramus and FFR of moderate LAD lesion Coronary artery disease: significant (50% or greater) lesion in a major coronary artery.
PRIOR DIAGNOSTIC TEST RESULTS: Nuclear stress test was positive. There was ischemia in the territory of the circumflex.
CORONARY VESSELS: Left main: Normal. LAD: There was a 50 % stenosis in the middle third of the vessel segment. 1st diagonal: There was a 50 % stenosis. Circumflex: There was a 0 % stenosis at the site of a prior stent, in the distal third of the vessel segment. Ramus intermedius: There was a 100 % stenosis. There was TIMI grade 1 flow through the vessel (slow flow without perfusion). This lesion is a chronic total occlusion.
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.
-- Right femoral 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 sheath was advanced over the wire into the vessel.
-- 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.
-- ULTRASOUND OF VESSEL..
Test started at 09:15. Test concluded at 10:27. RADIATION EXPOSURE:
Fluoroscopy time: 19.4 min.
CONTRAST GIVEN:
Omnipaque 70 ml.
Angiographic findings
Native coronary lesions:
7LAD: Lesion 1: 50 % stenosis.
7D1: Lesion 1: 50 % stenosis.
7Circumflex: Lesion 1: 0 % stenosis, site of prior stent.
7Ramus intermedius: Lesion 1: 100 % stenosis.
HEMODYNAMIC TABLES
Pressures: Baseline
Pressures: - HR: 84
Pressures: - Rhythm:
Pressures: -- Aortic Pressure (S/D/M): 191/137/158
Outputs: Baseline
Outputs: -- CALCULATIONS: Age in years: 65.41
Outputs: -- CALCULATIONS: Body Surface Area: 2.09
Outputs: -- CALCULATIONS: Height in cm: 175.00
Outputs: -- CALCULATIONS: Sex: Male
Outputs: -- CALCULATIONS: Weight in kg: 93.40
