Dzinze
New
My office manager codes all of the procedures and she's on vacation... She also took our coding books with her so I can't look anything up. My first time coding procedures and I need help with one! I'm having trouble choosing the correct codes by the EMR program descriptions. Does anyone have a cheat sheet or can direct me any helpful links? The report is as follows...
Procedure Type
*
Diagnostic procedure: Venous Graft Angiography, LIMA Graft Angiography,
Coronary Angiography
Miscellaneous: Closure Device Insertion
Registration Data
Registration Date: 07/02/2018 Registration Time: 09:28
*
Medical History
Allergies
- NKA:Sensitivity: Allergy.
*
Procedure Data
Procedure Date
Date: 07/02/2018Start: 13:15End: 14:35
*
The procedure was explained in detail to the patient. Risks, complications
and alternative treatments were reviewed. Written consent was obtained.
*
Diagnostic Cath Status: Elective
*
Entry Locations
- Retrograde Percutaneous access was performed through the Right Femoral
artery (Primary location). A 4 Fr sheath was inserted. This was
exchanged for a 6 Fr sheath. Hemostasis was successfully obtained using
Perclose ProGlide (Abbott).
*
Procedure Medications
- Versed/Midazolam I.V. 0.5 mg.
*
- Fentanyl/Sublimaze I.V. 25 mcg.
*
- Fentanyl/Sublimaze I.V. 25 mcg.
*
- Versed/Midazolam I.V. 0.5 mg.
*
- Fentanyl/Sublimaze I.V. 25 mcg.
*
- Lidocaine 2% S.Q. 10 ml.
*
Diagnostic Catheters
- A6 FrCordis 6F Infiniti JL4 100cmwas used for:*Left coronary
angiography.
*
- A6 FrCordis 6F Infiniti JR4 100cmwas used for:*Right coronary
angiography.
*
- A6 FrCordis 6F Infiniti JR4 100cmwas used for:*SVG.
*
- ACordis 6F Infiniti IM 100cm.was used for:*LIMA.
*
Complications: *No Complications.
*
Specimens Removed:
Contrast Material
- Visipaque (92002)105 ml
*
Fluoroscopy Time: Diagnostic: 11:21 minutes. Total: 11:21 minutes.
*
cGycm2 (T/R/F)7739/4152/3587 Cath Lab Rm #CCL 5
Primary ProcDiagnostic Air Kerma1018mGy
Patient Arrived Fromcau Patient Sent Toccl holding
*
Hemodynamics
Condition: Rest
O2 Consumption: Estimated: 258.65Heart Rate: 61 bpm
Pressures (mmHg)
+-----+--------------------------------------------------------------------+
!Site !Pressure (mmHg) !
+-----+--------------------------------------------------------------------+
!AO !163/62 (96) !
+-----+--------------------------------------------------------------------+
*
Shunts
*
Oxygen Values
O2 Capacity 145.52 O2 Consumption 258.65
Aorta Findings
Angiographic Findings
Cardiac Arteries and Lesion Findings
LAD:
The LAD is a moderate caliber vessel. The 1st diagonal branch is small.
Immediately after the 1st diagonal branch, there is a long "apple core" 99%
stenosis. Competitive flow is seen in the remainder of the LAD and the large
2nd diagonal branch. Distal LAD subtended by patent LIMA graft.
Lesion on Mid LAD: 99% stenosis 8 mm length.
LCx:
Circumflex is a large caliber vessel. There is mild disease in the proximal
portion. First obtuse marginal is subtotally occluded. Distally, there is a
large posterolateral branch. The left PDA is small in caliber. There is
moderate diffuse disease but no obstructive lesions.
Lesion on 1st Ob Marg: Ostial.100% stenosis.
RCA:
The RCA small and nondominant.
*
Cardiac Grafts
- There is a graft that originates at the Aorta Left and attaches to the
1st Ob Marg. Widely patent
- There is a graft that originates at the Aorta Left and attaches to the
2nd Diag. Widely patent
- There is a graft that originates at the LIMA and attaches to the Dist
LAD. Widely patent
Coronary Tree
Dominance: Left
Conclusions
Procedure Summary
Indication: Severe aortic stenosis
Coronary angiography performed via right femoral approach revealed
presence of a left dominant system. The LAD is subtotally occluded in the
midportion. First obtuse marginal is subtotally occluded at the ostium.
Circumflex is widely patent otherwise. The RCA small and not dominant.
There are 3 patent grafts including LIMA to LAD, SVG to 2nd diagonal and
SVG to 1st obtuse marginal.
Recommendations
Proceed with TAVR evaluation
Procedure Type
*
Diagnostic procedure: Venous Graft Angiography, LIMA Graft Angiography,
Coronary Angiography
Miscellaneous: Closure Device Insertion
Registration Data
Registration Date: 07/02/2018 Registration Time: 09:28
*
Medical History
Allergies
- NKA:Sensitivity: Allergy.
*
Procedure Data
Procedure Date
Date: 07/02/2018Start: 13:15End: 14:35
*
The procedure was explained in detail to the patient. Risks, complications
and alternative treatments were reviewed. Written consent was obtained.
*
Diagnostic Cath Status: Elective
*
Entry Locations
- Retrograde Percutaneous access was performed through the Right Femoral
artery (Primary location). A 4 Fr sheath was inserted. This was
exchanged for a 6 Fr sheath. Hemostasis was successfully obtained using
Perclose ProGlide (Abbott).
*
Procedure Medications
- Versed/Midazolam I.V. 0.5 mg.
*
- Fentanyl/Sublimaze I.V. 25 mcg.
*
- Fentanyl/Sublimaze I.V. 25 mcg.
*
- Versed/Midazolam I.V. 0.5 mg.
*
- Fentanyl/Sublimaze I.V. 25 mcg.
*
- Lidocaine 2% S.Q. 10 ml.
*
Diagnostic Catheters
- A6 FrCordis 6F Infiniti JL4 100cmwas used for:*Left coronary
angiography.
*
- A6 FrCordis 6F Infiniti JR4 100cmwas used for:*Right coronary
angiography.
*
- A6 FrCordis 6F Infiniti JR4 100cmwas used for:*SVG.
*
- ACordis 6F Infiniti IM 100cm.was used for:*LIMA.
*
Complications: *No Complications.
*
Specimens Removed:
Contrast Material
- Visipaque (92002)105 ml
*
Fluoroscopy Time: Diagnostic: 11:21 minutes. Total: 11:21 minutes.
*
cGycm2 (T/R/F)7739/4152/3587 Cath Lab Rm #CCL 5
Primary ProcDiagnostic Air Kerma1018mGy
Patient Arrived Fromcau Patient Sent Toccl holding
*
Hemodynamics
Condition: Rest
O2 Consumption: Estimated: 258.65Heart Rate: 61 bpm
Pressures (mmHg)
+-----+--------------------------------------------------------------------+
!Site !Pressure (mmHg) !
+-----+--------------------------------------------------------------------+
!AO !163/62 (96) !
+-----+--------------------------------------------------------------------+
*
Shunts
*
Oxygen Values
O2 Capacity 145.52 O2 Consumption 258.65
Aorta Findings
Angiographic Findings
Cardiac Arteries and Lesion Findings
LAD:
The LAD is a moderate caliber vessel. The 1st diagonal branch is small.
Immediately after the 1st diagonal branch, there is a long "apple core" 99%
stenosis. Competitive flow is seen in the remainder of the LAD and the large
2nd diagonal branch. Distal LAD subtended by patent LIMA graft.
Lesion on Mid LAD: 99% stenosis 8 mm length.
LCx:
Circumflex is a large caliber vessel. There is mild disease in the proximal
portion. First obtuse marginal is subtotally occluded. Distally, there is a
large posterolateral branch. The left PDA is small in caliber. There is
moderate diffuse disease but no obstructive lesions.
Lesion on 1st Ob Marg: Ostial.100% stenosis.
RCA:
The RCA small and nondominant.
*
Cardiac Grafts
- There is a graft that originates at the Aorta Left and attaches to the
1st Ob Marg. Widely patent
- There is a graft that originates at the Aorta Left and attaches to the
2nd Diag. Widely patent
- There is a graft that originates at the LIMA and attaches to the Dist
LAD. Widely patent
Coronary Tree
Dominance: Left
Conclusions
Procedure Summary
Indication: Severe aortic stenosis
Coronary angiography performed via right femoral approach revealed
presence of a left dominant system. The LAD is subtotally occluded in the
midportion. First obtuse marginal is subtotally occluded at the ostium.
Circumflex is widely patent otherwise. The RCA small and not dominant.
There are 3 patent grafts including LIMA to LAD, SVG to 2nd diagonal and
SVG to 1st obtuse marginal.
Recommendations
Proceed with TAVR evaluation
