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bhargavi

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Hemodynamics:

The left ventricular pressure was 5 mmHg. The aortic pressure was 137/65 mmHg.

Coronary Angiography:

Right coronary artery is 100% occluded at the ostium. Distal vessel is filling via left-to-right collaterals.

Left Main is angiographically normal.

Left anterior descending is a medium to large caliber vessel with ostial 60 to 70% stenosis, mild to moderate diffuse mid vessel disease, patent distal segment. This is a type III wraparound LAD. LAD is providing collaterals to distal RCA.
Diagonal 1 is a small to medium caliber vessel with ostial 50% stenosis, patent mid to distal segment. Diagonal 2 is a small caliber vessel appears angiographically normal.

Left circumflex is 100% occluded at the ostium. Sluggish flow noted into obtuse marginal 1 branch which appears to be the culprit vessel for acute MI.

Left subclavian selective angiography revealed patent left subclavian artery and IMA.

Left ventriculogram: Left ventricular cavity was entered using 5 French JR4 diagnostic catheter and LVEDP was measured at 5 mmHg.

The patient was then transferred to the recovery area in stable condition:

Summary conclusion:

1. Multivessel CAD
2. Hypertension
3. Dyslipidemia
4. Type 2 diabetes mellitus
5. CKD
6. NSTEMI

Recommendation:

Recommend CT surgery evaluation for CABG.

thanks in advance
i am thinking of 93459 to be billed. physician has billed 93458, 36225
pl help with coding
 
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