smiller
Networker
Hello everyone - I need help with this report, I am trying to learn the new cervicocerebral codes - please check my coding and give thoughts, advice etc.
PROCEDURE PERFORMED.
1. Selective angiogram of the left coronary system.
2. Selective angiography of the right coronary system.
3. Left ventriculogram.
4. Abdominal aortogram and bilateral nonselective renal
arteriogram.
5. Right brachiocephalic trunk arteriogram with nonselective
right subclavian and right vertebral arteriogram.
6. Right common carotid angiogram with intracranial angiogram
of the right carotid circulation.
7. Left common carotid angiogram followed with intracranial
angiogram of left carotid circulation.
8. Left subclavian arteriogram with nonselective left
vertebral artery angiogram.
REPORT IS AS FOLLOWS: The patient was brought to the
catheterization laboratory. The right groin area was
anesthetized. A 6-French sheath was placed. Through this sheath
angiogram of the left and right coronary arteries, left
ventriculogram, abdominal aortogram and carotid angiography
revealed the following:
FINDINGS:
LEFT MAIN: Left main coronary artery arises from the left sinus
of Valsalva. It divides into the left anterior descending, left
circumflex. Left main coronary artery is angiographically normal.
LEFT ANTERIOR DESCENDING in the proximal portion and the
midportion has long calcific 90% stenosis. It gives off two
small caliber diagonal vessels.
LEFT CIRCUMFLEX ARTERY gives off two obtuse marginals. It has a
very proximal hazy 40% stenosis, then obtuse marginal 1 has mild
luminal irregularities. Obtuse marginal 2 has a proximal 50%
stenosis.
CARDIAC CATHETERIZATION
Page 1 of 3
dat 796210 DT: 01/07/2013 19:15
DD: 01/07/2013 09:03
CARDIAC CATHETERIZATION
RIGHT CORONARY ARTERY is a small caliber vessel with a mid 80%
stenosis and long tubular segment with calcification.
LEFT VENTRICLE: Left ventricular end-diastolic pressure 20 mmHg.
Normal left ventricular wall motion and systolic function.
Ejection fraction 60%. No mitral regurgitation is noted.
ABDOMINAL AORTOGRAM shows patent bilateral single renal arterials.
CAROTID ANGIOGRAM shows patent brachiocephalic trunk, patient
right subclavian artery, patent right vertebral artery, patent
right common carotid. The right internal carotid artery has 10%
stenosis at its origin in the carotid bulb and thereafter has a
band which is about 40% to 50% stenosis but no calcification is
noted, and this seems to be tortuous area of the internal carotid
artery. Right external carotid artery is patent. Left common
carotid patent. Left external carotid patent. Left internal
carotid artery has central 50% stenosis at its carotid bulb.
Left subclavian is patent and left vertebral is patent.
Intracranial circulation was patent bilateral anterior cerebral
arteries and bilateral middle cerebral arteries with excellent
venous phase.
PLAN was to proceed with percutaneous intervention. CLS 3.0
guide catheter was used. BMW wire was used to cross the lesion
in the left anterior descending. It was predilated with 2.5 x 15
balloon followed with a 2.75 x 26 Resolute stent, postdilated
with a 3.0 x 15 noncompliant balloon. After this, the catheters
were removed. Catheterization showed excellent angiographic
result with no residual stenosis. No side branch occlusion or
dissection.
FFR 4 short tipped catheter used to engage the right coronary
artery. BMW wire was used. Direct stenting was performed with 2.
25 x 30 mm Resolute stent, postdilated with 2.5 x 15 mm
noncompliant balloon. Excellent angiographic results. All
catheters and wires removed. Hemostasis obtained by applying
__________.
CARDIAC CATHETERIZATION
Page 2 of 3
dat 796210 DT: 01/07/2013 19:15
DD: 01/07/2013 09:03
IMPRESSION:
1. Successful percutaneous intervention of left anterior
descending and right coronary artery critically stenosed
lesions.
2. Successful sedation.
PLAN: Aspirin for life. Plavix 300 mg given on the table. To
continue cigarette and peripheral arterial disease risk
modification.
Here's what I come up with: 92928-LD
92929-RC
93458-26-51
36216-59-RT (RCC)
36215-59-LT (LCC)
36215-59-LT (left subclavian)
36223-50
36225 (selective left subclavian)
Thank you.
Sheryl, CCC
Memphis, TN
PROCEDURE PERFORMED.
1. Selective angiogram of the left coronary system.
2. Selective angiography of the right coronary system.
3. Left ventriculogram.
4. Abdominal aortogram and bilateral nonselective renal
arteriogram.
5. Right brachiocephalic trunk arteriogram with nonselective
right subclavian and right vertebral arteriogram.
6. Right common carotid angiogram with intracranial angiogram
of the right carotid circulation.
7. Left common carotid angiogram followed with intracranial
angiogram of left carotid circulation.
8. Left subclavian arteriogram with nonselective left
vertebral artery angiogram.
REPORT IS AS FOLLOWS: The patient was brought to the
catheterization laboratory. The right groin area was
anesthetized. A 6-French sheath was placed. Through this sheath
angiogram of the left and right coronary arteries, left
ventriculogram, abdominal aortogram and carotid angiography
revealed the following:
FINDINGS:
LEFT MAIN: Left main coronary artery arises from the left sinus
of Valsalva. It divides into the left anterior descending, left
circumflex. Left main coronary artery is angiographically normal.
LEFT ANTERIOR DESCENDING in the proximal portion and the
midportion has long calcific 90% stenosis. It gives off two
small caliber diagonal vessels.
LEFT CIRCUMFLEX ARTERY gives off two obtuse marginals. It has a
very proximal hazy 40% stenosis, then obtuse marginal 1 has mild
luminal irregularities. Obtuse marginal 2 has a proximal 50%
stenosis.
CARDIAC CATHETERIZATION
Page 1 of 3
dat 796210 DT: 01/07/2013 19:15
DD: 01/07/2013 09:03
CARDIAC CATHETERIZATION
RIGHT CORONARY ARTERY is a small caliber vessel with a mid 80%
stenosis and long tubular segment with calcification.
LEFT VENTRICLE: Left ventricular end-diastolic pressure 20 mmHg.
Normal left ventricular wall motion and systolic function.
Ejection fraction 60%. No mitral regurgitation is noted.
ABDOMINAL AORTOGRAM shows patent bilateral single renal arterials.
CAROTID ANGIOGRAM shows patent brachiocephalic trunk, patient
right subclavian artery, patent right vertebral artery, patent
right common carotid. The right internal carotid artery has 10%
stenosis at its origin in the carotid bulb and thereafter has a
band which is about 40% to 50% stenosis but no calcification is
noted, and this seems to be tortuous area of the internal carotid
artery. Right external carotid artery is patent. Left common
carotid patent. Left external carotid patent. Left internal
carotid artery has central 50% stenosis at its carotid bulb.
Left subclavian is patent and left vertebral is patent.
Intracranial circulation was patent bilateral anterior cerebral
arteries and bilateral middle cerebral arteries with excellent
venous phase.
PLAN was to proceed with percutaneous intervention. CLS 3.0
guide catheter was used. BMW wire was used to cross the lesion
in the left anterior descending. It was predilated with 2.5 x 15
balloon followed with a 2.75 x 26 Resolute stent, postdilated
with a 3.0 x 15 noncompliant balloon. After this, the catheters
were removed. Catheterization showed excellent angiographic
result with no residual stenosis. No side branch occlusion or
dissection.
FFR 4 short tipped catheter used to engage the right coronary
artery. BMW wire was used. Direct stenting was performed with 2.
25 x 30 mm Resolute stent, postdilated with 2.5 x 15 mm
noncompliant balloon. Excellent angiographic results. All
catheters and wires removed. Hemostasis obtained by applying
__________.
CARDIAC CATHETERIZATION
Page 2 of 3
dat 796210 DT: 01/07/2013 19:15
DD: 01/07/2013 09:03
IMPRESSION:
1. Successful percutaneous intervention of left anterior
descending and right coronary artery critically stenosed
lesions.
2. Successful sedation.
PLAN: Aspirin for life. Plavix 300 mg given on the table. To
continue cigarette and peripheral arterial disease risk
modification.
Here's what I come up with: 92928-LD
92929-RC
93458-26-51
36216-59-RT (RCC)
36215-59-LT (LCC)
36215-59-LT (left subclavian)
36223-50
36225 (selective left subclavian)
Thank you.
Sheryl, CCC
Memphis, TN