amym
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Would this still be coded as a left heart cath, 93458? What aspect of the note helped determine the code? -Thanks in advance.
ACCESS: The radial artery was accessed for this procedure. Another doctor gained access for this examination. Catheter angiograms were performed by myself under his guidance.
LEFT CIRCUMFLEX: Moderate-sized vessel. Left circumflex has an early course in the proximal vessel into the AV groove. The left circumflex has an early course in the proximal vessel into the AV groove. The left circumflex distally gives off a trifurcating, large-sized obtuse marginal branch. There is 40% stenosis prior to this obtuse marginal branch. The remainder of the left circumflex artery has mild-to-moderate luminal irregularities.
LEFT ANTERIOR DESCENDING ARTERY: Moderate-sized vessel. Previously placed stent is patent. The proximal portion of the stent has moderate in-stent restenosis. Distally, there is a 70% de novo stenosis in the LAD.
LEFT MAIN: Moderate-sized vessel. Mild-to-moderate luminal irregularities. There is a 20% stenosis at the level of the ostial LAD.
DIAGONAL: There are diagonal branches noted that are small in the mid and distal portions of the LAD. The diagonal branch involving the distal LAD stenosis has a 90% ostial stenosis.
RIGHT CORONARY ARTERY: Dominant vessel. There is 40% ostial proximal stenosis. There is a discrete 50% stenosis in the distal proximal region. Otherwise, mild-to-moderate luminal irregularities are noted.
LV GRAM: Moderate mid-to-distal and apical hypokinesis noted. No significant gradient was noted across the aortic valve.
IMPRESSION
ACCESS: The radial artery was accessed for this procedure. Another doctor gained access for this examination. Catheter angiograms were performed by myself under his guidance.
LEFT CIRCUMFLEX: Moderate-sized vessel. Left circumflex has an early course in the proximal vessel into the AV groove. The left circumflex has an early course in the proximal vessel into the AV groove. The left circumflex distally gives off a trifurcating, large-sized obtuse marginal branch. There is 40% stenosis prior to this obtuse marginal branch. The remainder of the left circumflex artery has mild-to-moderate luminal irregularities.
LEFT ANTERIOR DESCENDING ARTERY: Moderate-sized vessel. Previously placed stent is patent. The proximal portion of the stent has moderate in-stent restenosis. Distally, there is a 70% de novo stenosis in the LAD.
LEFT MAIN: Moderate-sized vessel. Mild-to-moderate luminal irregularities. There is a 20% stenosis at the level of the ostial LAD.
DIAGONAL: There are diagonal branches noted that are small in the mid and distal portions of the LAD. The diagonal branch involving the distal LAD stenosis has a 90% ostial stenosis.
RIGHT CORONARY ARTERY: Dominant vessel. There is 40% ostial proximal stenosis. There is a discrete 50% stenosis in the distal proximal region. Otherwise, mild-to-moderate luminal irregularities are noted.
LV GRAM: Moderate mid-to-distal and apical hypokinesis noted. No significant gradient was noted across the aortic valve.
IMPRESSION
