amym
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Would this note qualify for billing a 92941 or 92943 or it's just a 92928? Thanks
-- CORONARY CIRCULATION:
-- Mid LAD: There was a diffuse 100 % stenosis. There was good collateral
blood supply to the distal myocardium. This lesion is a chronic total
occlusion.
-- 1ST LESION INTERVENTIONS:
-- A drug-eluting stent was performed on the 100 % lesion in the proximal
LAD. -- A PE Plus MR 2.5 x 20 drug-eluting stent was placed across the
lesion and deployed at a maximum inflation pressure of 15 atm.
PROCEDURES PERFORMED:
-- Coronary Drug Eluding Stent Placement.
-- Interventional OCT.
-- Intervention on proximal LAD: .
INDICATIONS: Angina/MI: stable angina.
HEMODYNAMICS: Hemodynamic assessment demonstrates normal hemodynamics.
CORONARY VESSELS: The coronary circulation is right dominant. Proximal
LAD: There was a 100 % stenosis. There was TIMI grade 0 flow through the
vessel (no flow). Mid LAD: There was a diffuse 100 % stenosis. There was
good collateral blood supply to the distal myocardium. This lesion is a
chronic total occlusion.
PROCEDURE: The risks and alternatives of the procedures and conscious
sedation were explained to the patient and informed consent was obtained.
The patient was brought to the cath lab and placed on the table. The
planned puncture sites were prepped and draped in the usual sterile
fashion.
-- Right radial artery access. The puncture site was infiltrated with
local anesthetic. The vessel was accessed using the modified Seldinger
technique, a wire was threaded into the vessel, and a catheter was
advanced over the wire into the vessel.
LESION INTERVENTION: A drug-eluting stent was performed on the 100 %
lesion in the proximal LAD. This was an ACC/AHA type C "high risk" lesion
for intervention. There was TIMI 0 flow before the procedure. There was no
acute vessel closure. There was no perforation. There was no dissection.
-- Vessel setup was performed. A BMW HT 190cm wire was used to cross the
lesion.
-- Vessel setup was performed. A Runway 6FR LBU 3.5 guiding catheter was
used to cannulate the vessel.
-- Balloon angioplasty was performed, using a Sprinter 1.25 X 12 balloon,
with 2 inflations and a maximum inflation pressure of 15 atm.
-- Balloon angioplasty was performed, using a Apex Push 1.5 x 12 balloon,
with 3 inflations and a maximum inflation pressure of 15 atm.
-- A PE Plus MR 2.50 x 32 drug-eluting stent placement was attempted, but
would not cross the lesion and was removed at a maximum inflation pressure
of 14 atm.
-- Balloon angioplasty was performed, using a Emerge Rx 2.25 x 15mm
balloon, with 4 inflations and a maximum inflation pressure of 15 atm.
-- A PE Plus MR 2.5 x 20 drug-eluting stent was placed across the lesion
and deployed at a maximum inflation pressure of 15 atm.
-- Balloon angioplasty was performed, using a NC Quantum 3.0 x 12
balloon, with 4 inflations and a maximum inflation pressure of 17 atm.
-- An OCT, using a Dragonfly Pressure Kit.
CARDIAC INTERVENTIONS
-- Coronary Drug Eluding Stent Placement.
-- Interventional OCT.
-- CORONARY CIRCULATION:
-- Mid LAD: There was a diffuse 100 % stenosis. There was good collateral
blood supply to the distal myocardium. This lesion is a chronic total
occlusion.
-- 1ST LESION INTERVENTIONS:
-- A drug-eluting stent was performed on the 100 % lesion in the proximal
LAD. -- A PE Plus MR 2.5 x 20 drug-eluting stent was placed across the
lesion and deployed at a maximum inflation pressure of 15 atm.
PROCEDURES PERFORMED:
-- Coronary Drug Eluding Stent Placement.
-- Interventional OCT.
-- Intervention on proximal LAD: .
INDICATIONS: Angina/MI: stable angina.
HEMODYNAMICS: Hemodynamic assessment demonstrates normal hemodynamics.
CORONARY VESSELS: The coronary circulation is right dominant. Proximal
LAD: There was a 100 % stenosis. There was TIMI grade 0 flow through the
vessel (no flow). Mid LAD: There was a diffuse 100 % stenosis. There was
good collateral blood supply to the distal myocardium. This lesion is a
chronic total occlusion.
PROCEDURE: The risks and alternatives of the procedures and conscious
sedation were explained to the patient and informed consent was obtained.
The patient was brought to the cath lab and placed on the table. The
planned puncture sites were prepped and draped in the usual sterile
fashion.
-- Right radial artery access. The puncture site was infiltrated with
local anesthetic. The vessel was accessed using the modified Seldinger
technique, a wire was threaded into the vessel, and a catheter was
advanced over the wire into the vessel.
LESION INTERVENTION: A drug-eluting stent was performed on the 100 %
lesion in the proximal LAD. This was an ACC/AHA type C "high risk" lesion
for intervention. There was TIMI 0 flow before the procedure. There was no
acute vessel closure. There was no perforation. There was no dissection.
-- Vessel setup was performed. A BMW HT 190cm wire was used to cross the
lesion.
-- Vessel setup was performed. A Runway 6FR LBU 3.5 guiding catheter was
used to cannulate the vessel.
-- Balloon angioplasty was performed, using a Sprinter 1.25 X 12 balloon,
with 2 inflations and a maximum inflation pressure of 15 atm.
-- Balloon angioplasty was performed, using a Apex Push 1.5 x 12 balloon,
with 3 inflations and a maximum inflation pressure of 15 atm.
-- A PE Plus MR 2.50 x 32 drug-eluting stent placement was attempted, but
would not cross the lesion and was removed at a maximum inflation pressure
of 14 atm.
-- Balloon angioplasty was performed, using a Emerge Rx 2.25 x 15mm
balloon, with 4 inflations and a maximum inflation pressure of 15 atm.
-- A PE Plus MR 2.5 x 20 drug-eluting stent was placed across the lesion
and deployed at a maximum inflation pressure of 15 atm.
-- Balloon angioplasty was performed, using a NC Quantum 3.0 x 12
balloon, with 4 inflations and a maximum inflation pressure of 17 atm.
-- An OCT, using a Dragonfly Pressure Kit.
CARDIAC INTERVENTIONS
-- Coronary Drug Eluding Stent Placement.
-- Interventional OCT.