I had the pleasure of seeing your patient, Mr. *********, for an evaluation at the ****** Cardiology ****** office today. As you are aware, he is a 58-year-old gentleman who was previously a patient of Dr. ****** and was last seen on September 28, 2007. He has known history of coronary artery disease and underwent cardiac catheterization on February 1, 2007, after an abnormal stress test. Left main had 20% stenosis. The LAD had a mid 85% stenosis involving the ostium of a small second diagonal artery. The left circumflex artery is a dominant vessel with no significant disease. The AV groove branch of the left circumflex artery gives rise to a medium-caliber left posterolateral artery which has a long tubular stenosis of 85-90% stenosis. He underwent stenting to the LAD with a 2.75 x 16 mm Taxus stent and a 3 x 20 mm Taxus stent. The distal left circumflex artery was treated with balloon angioplasty with a 2.5 x 30 mm Maverick balloon. He did not receive any stents to that vessel.
Since that time, he has been doing well from a cardiac standpoint with no chest discomfort or shortness of breath. He used to be very active, but over the past few months has been dealing with an infected right first toe and is not able to do much exertion because of it. He denies PND or orthopnea. Since it has been a while from his last cardiac evaluation, he was scheduled for an outpatient dobutamine stress echocardiogram. Baseline echo shows normal left ventricular size and systolic function with ejection fraction of 60-65%. There is grade 1 diastolic dysfunction. There were no significant valvular abnormalities. As the lateral wall was never well seen, the patient was brought back on January 13, 2015, for a Lexiscan nuclear stress test. This showed a small fixed inferobasal defect of mild to moderate intensity with no reversible ischemia. He had normal left ventricular systolic function with ejection fraction of 60% with decreased wall thickening involving the inferobasal wall. In comparison with his previous exercise nuclear stress test from January 3, 2007, the small fixed inferior defect was old. There was a previous moderate-sized reversible lateral defect on the January 3, 2007, study that was not noted on the current study. Because of the stress test, he was referred for an evaluation today.
My question is, how would you code the HPI & ROS with the above information? Also, the patient was sent here for a Stress Echo. That was abnormal and we scheduled the Nuclear stress. "After" the nuclear, the patient came back in for a new patient eval to go over the testing. Can I use the Moderate unter Table of Risk for Stress test ordered? Not sure about this one because we ordered it prior to seeing the patient?
Thanks!!!!!!
Since that time, he has been doing well from a cardiac standpoint with no chest discomfort or shortness of breath. He used to be very active, but over the past few months has been dealing with an infected right first toe and is not able to do much exertion because of it. He denies PND or orthopnea. Since it has been a while from his last cardiac evaluation, he was scheduled for an outpatient dobutamine stress echocardiogram. Baseline echo shows normal left ventricular size and systolic function with ejection fraction of 60-65%. There is grade 1 diastolic dysfunction. There were no significant valvular abnormalities. As the lateral wall was never well seen, the patient was brought back on January 13, 2015, for a Lexiscan nuclear stress test. This showed a small fixed inferobasal defect of mild to moderate intensity with no reversible ischemia. He had normal left ventricular systolic function with ejection fraction of 60% with decreased wall thickening involving the inferobasal wall. In comparison with his previous exercise nuclear stress test from January 3, 2007, the small fixed inferior defect was old. There was a previous moderate-sized reversible lateral defect on the January 3, 2007, study that was not noted on the current study. Because of the stress test, he was referred for an evaluation today.
My question is, how would you code the HPI & ROS with the above information? Also, the patient was sent here for a Stress Echo. That was abnormal and we scheduled the Nuclear stress. "After" the nuclear, the patient came back in for a new patient eval to go over the testing. Can I use the Moderate unter Table of Risk for Stress test ordered? Not sure about this one because we ordered it prior to seeing the patient?
Thanks!!!!!!