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I need assistance coding the following procedure:
1. MODERATE IV SEDATION AND MONITORING
2. CORONARY ANGIOGRAM
3. LIMA ANGIOGRAM
4. SVG ANGIOGRAM
5. MYNX CLOSURE
Preoperative Diagnosis: CAD (coronary artery disease) (ICD10-CM I25.10, Discharge, Medical), ACS (acute coronary
syndrome) (ICD10-CM I24.9, Discharge, Medical).
Postoperative Diagnosis: Same, 3V NATIVE CAD, LIMA/LAD OCCLUDED AT ANASTAMOSIS, SVG/OM & SVG/RCA
PATENT.
Findings: AFTER THE RISK, BENEFITS, AND ALTERNATIVES TO CARDIAC CATHETERIZATION WERE EXPLAINED IN DETAIL TO THE PATIENT, INFORMED CONSENT WAS OBTAINED. THE PATIENT WAS BROUGHT TO THE CATH LAB AND PREPPED AND DRAPED IN THE USUAL FASHION. MODERATE IV SEDATION WAS ADMINISTERED WHILE THE PATIENT WAS MONITORED CLOSELY.
AFTER 1% LIDOCAINE WAS ADMINISTERED FOR LOCAL ANESTHESIA, A MICROPUNCTURE TECHNIQUE WAS USED TO ACCESS THE FEMORAL ARTERY AND A 6 FR SHEATH WAS INSERTED. THE JL4/JR4 CATHETERS WERE USED TO SELECTIVELY CANNULATE THE CORONARY ARTERIES AND OBTAIN ANGIOGRAPHIC IMPAGES AND HEMODYNAMIC MEASUREMENTS. AFTER THE CARDIAC PROCEDURE WAS COMPLETED, A MYNX DEVICE WAS USED TO ACHIEVE HEMOSTASIS. THE PATIENT TOLERATED THE PROCEDURE WELL AND WAS TRANSFERRED TO THE RECOVERY ROOM IN
STABLE CONDITION.
MODERATE CONSCIOUS SEDATION TIME: 26 MINUTES
HEMODYNAMICS: AORTA 117/62 mmHg, MEAN Ao 84 mmHg
FINDINGS:
LM: MODERATE SIZE, DISTAL 80% LESION
LAD: LARGE, OSTIAL 90% LESION, MILD DISEASE OTHERWISE, REFLUX INTO LIMA GRAFT NOT SEEN
LCX: NON-DOMINANT, OSTIAL 80% LESION, DISTAL 80% LESION, MILD DISEASE OTHERWISE. OM2 FLUSH
OCCLUDED AT OSTIUM AND FILLS VIA SVG
RCA: DOMINANT, LARGE, DISTAL 80% LESION, FILLS VIA SVG
LIMA/LAD: RELATIVE SMALL CALIBER, PROXIMAL BRANCH NOTED, SUBTOTAL/COMPLETE OCCLUSION AT
ANASTAMOSIS
SVG/OM: RELATIVELY SMALL CALIBER, PROXIMAL AND MID 40% LESIONS
SVG/RCA: LARGE, WIDELY PATENT
PORCINE AV APPARATUS VISUALIZED UNDER FLUOROSCOPY.
IMPRESSION:
1. 3V NATIVE CAD, LIMA/LAD OCCLUDED AT ANASTAMOSIS, SVG/OM & SVG/RCA PATENT
1. MODERATE IV SEDATION AND MONITORING
2. CORONARY ANGIOGRAM
3. LIMA ANGIOGRAM
4. SVG ANGIOGRAM
5. MYNX CLOSURE
Preoperative Diagnosis: CAD (coronary artery disease) (ICD10-CM I25.10, Discharge, Medical), ACS (acute coronary
syndrome) (ICD10-CM I24.9, Discharge, Medical).
Postoperative Diagnosis: Same, 3V NATIVE CAD, LIMA/LAD OCCLUDED AT ANASTAMOSIS, SVG/OM & SVG/RCA
PATENT.
Findings: AFTER THE RISK, BENEFITS, AND ALTERNATIVES TO CARDIAC CATHETERIZATION WERE EXPLAINED IN DETAIL TO THE PATIENT, INFORMED CONSENT WAS OBTAINED. THE PATIENT WAS BROUGHT TO THE CATH LAB AND PREPPED AND DRAPED IN THE USUAL FASHION. MODERATE IV SEDATION WAS ADMINISTERED WHILE THE PATIENT WAS MONITORED CLOSELY.
AFTER 1% LIDOCAINE WAS ADMINISTERED FOR LOCAL ANESTHESIA, A MICROPUNCTURE TECHNIQUE WAS USED TO ACCESS THE FEMORAL ARTERY AND A 6 FR SHEATH WAS INSERTED. THE JL4/JR4 CATHETERS WERE USED TO SELECTIVELY CANNULATE THE CORONARY ARTERIES AND OBTAIN ANGIOGRAPHIC IMPAGES AND HEMODYNAMIC MEASUREMENTS. AFTER THE CARDIAC PROCEDURE WAS COMPLETED, A MYNX DEVICE WAS USED TO ACHIEVE HEMOSTASIS. THE PATIENT TOLERATED THE PROCEDURE WELL AND WAS TRANSFERRED TO THE RECOVERY ROOM IN
STABLE CONDITION.
MODERATE CONSCIOUS SEDATION TIME: 26 MINUTES
HEMODYNAMICS: AORTA 117/62 mmHg, MEAN Ao 84 mmHg
FINDINGS:
LM: MODERATE SIZE, DISTAL 80% LESION
LAD: LARGE, OSTIAL 90% LESION, MILD DISEASE OTHERWISE, REFLUX INTO LIMA GRAFT NOT SEEN
LCX: NON-DOMINANT, OSTIAL 80% LESION, DISTAL 80% LESION, MILD DISEASE OTHERWISE. OM2 FLUSH
OCCLUDED AT OSTIUM AND FILLS VIA SVG
RCA: DOMINANT, LARGE, DISTAL 80% LESION, FILLS VIA SVG
LIMA/LAD: RELATIVE SMALL CALIBER, PROXIMAL BRANCH NOTED, SUBTOTAL/COMPLETE OCCLUSION AT
ANASTAMOSIS
SVG/OM: RELATIVELY SMALL CALIBER, PROXIMAL AND MID 40% LESIONS
SVG/RCA: LARGE, WIDELY PATENT
PORCINE AV APPARATUS VISUALIZED UNDER FLUOROSCOPY.
IMPRESSION:
1. 3V NATIVE CAD, LIMA/LAD OCCLUDED AT ANASTAMOSIS, SVG/OM & SVG/RCA PATENT