OPENSHAW
Guru
Could someone please look over this procedure report for me!
Would the following report be codes as:
1.) 93455-26, DX. 414.00
2.) 37236, DX. 405.91
3.) 36252, DX. 405.91
Procedure Report reads as follows:
Patient has Renovascular hypertension and coronary artery disease.
Procedures:
Selective coronary arteriogram. Coronary bypass angiography. Bilateral selective renal angiogram and right renal stenting. Femoral closure.
Description of the procedure:
Upon obtaining approved consent the patient was brought to the cath lab. The right femoral area was prepped in the usual fashion. 20 cc of undiluted lidocaine with 4 cc of bicarb were infiltrated and local anesthesia was achieved. The right femoral artery was cannulated with the Seldinger technique. A 6 F sheath was introduced. Femoral angiogram was done to assess the position of the sheath and be sure was above the bifurcation of the femoral artery. A JL 3.5 was utilized to opacify the left coronary artery in multiple projections the catheter was then exchanged for an AR1 catheter that cannulated 2 Saphenous vein grafts. Thereafter the RDC renal guide was utilized to opacify the right renal artery where 70% long stenosis in the proximal third of the vessel. Thereafter the left renal artery was cannulated and found to be normal. A decision was made to intervene 5000 units of heparin were given. ACT was prolonged to 253 the guid was changed to RDC1 that was more selective and coaxial with the right artery. An 018 Spartacore wire was used to cross the lesion and a Palmaz Blue stent 7.33 x 24 was positioned at the site of the lesion confirmed by angiography after recording a gradient in excess of 55 mm of Hg. The stent was deployed at 8 ATM for 30 secs. The gradient was abolished. The stent and wire were removed and final angiography confirmed an excellent angiographic result.
The patient tolerated the procedure well.
Final closure with an Angioseal 8F achieved hemostasis.
The patient was sent to the recovery room in good condition.
Thank you!
Would the following report be codes as:
1.) 93455-26, DX. 414.00
2.) 37236, DX. 405.91
3.) 36252, DX. 405.91
Procedure Report reads as follows:
Patient has Renovascular hypertension and coronary artery disease.
Procedures:
Selective coronary arteriogram. Coronary bypass angiography. Bilateral selective renal angiogram and right renal stenting. Femoral closure.
Description of the procedure:
Upon obtaining approved consent the patient was brought to the cath lab. The right femoral area was prepped in the usual fashion. 20 cc of undiluted lidocaine with 4 cc of bicarb were infiltrated and local anesthesia was achieved. The right femoral artery was cannulated with the Seldinger technique. A 6 F sheath was introduced. Femoral angiogram was done to assess the position of the sheath and be sure was above the bifurcation of the femoral artery. A JL 3.5 was utilized to opacify the left coronary artery in multiple projections the catheter was then exchanged for an AR1 catheter that cannulated 2 Saphenous vein grafts. Thereafter the RDC renal guide was utilized to opacify the right renal artery where 70% long stenosis in the proximal third of the vessel. Thereafter the left renal artery was cannulated and found to be normal. A decision was made to intervene 5000 units of heparin were given. ACT was prolonged to 253 the guid was changed to RDC1 that was more selective and coaxial with the right artery. An 018 Spartacore wire was used to cross the lesion and a Palmaz Blue stent 7.33 x 24 was positioned at the site of the lesion confirmed by angiography after recording a gradient in excess of 55 mm of Hg. The stent was deployed at 8 ATM for 30 secs. The gradient was abolished. The stent and wire were removed and final angiography confirmed an excellent angiographic result.
The patient tolerated the procedure well.
Final closure with an Angioseal 8F achieved hemostasis.
The patient was sent to the recovery room in good condition.
Thank you!
