missbren71
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What diagnosis codes would you use for the following:
INDICATIONS FOR PROCEDURES:
This is a 92-year-old male with a history of PAD. He has ulceration of his toes as well as chronic pain in his right foot.
He presents for angiogram with possible intervention. He understands the
risks of the procedures which include but are not limited to bleeding,
infection, need for further operation, damage to vessels, need for repair,
need for later distal bypass surgery, or inability to vascularize
resulting in amputation. He understands these risks and agrees to the
procedures.
RADIOGRAPHIC FINDINGS:
1. Aortogram with patent right renal artery. Left renal artery not
visualized. Distal aorta with no significant stenosis. Approximately
50% right common iliac stenosis. Patent right common femoral and
profunda femoris.
2. Occluded right superficial femoral and popliteal arteries.
3. Patent proximal right anterior tibial artery with distal occlusion
at the level of the ankle. Occluded right peroneal and posterior
tibial arteries.
4. No significant runoff to right foot.
DESCRIPTION OF PROCEDURES:
The patient was brought to the operating room. There was concern due to
his age that general anesthesia would be required. However, monitored
anesthetic care was administered. The bilateral groins were sterilely
prepped and draped. A time out procedure was performed. The left groin
was anesthetized with 1% lidocaine.
The left common femoral artery was punctured using a micropuncture
technique. A .035 guidewire was placed in the abdominal aorta. A 5-
French sheath was placed in the right groin. An Omni catheter was placed
into the abdominal aorta, and a flush aortogram was performed. A Swan-
Ganz catheterization was then performed. Multiple pelvic views were
obtained due to a moderate stenosis of the right common iliac artery.
However, this appeared to be an approximately 50% stenosis, and no
intervention was required. A Swan-Ganz catheterization was then performed
to the level of the distal right external iliac artery.
Elective angiogram was then performed of the right lower extremity.
Findings are listed above. No intervention was deemed appropriate. The
future care will require medical management of his wound and chronic pain.
Further revascularization is not possible due to poor runoff. The
catheter was then removed. The left 5-French sheath was removed over a
guidewire.
A percutaneous closure was performed using an Angio-Seal device. There
was no evidence of active bleeding or extension hematoma upon completion.
Thank you in advance.
INDICATIONS FOR PROCEDURES:
This is a 92-year-old male with a history of PAD. He has ulceration of his toes as well as chronic pain in his right foot.
He presents for angiogram with possible intervention. He understands the
risks of the procedures which include but are not limited to bleeding,
infection, need for further operation, damage to vessels, need for repair,
need for later distal bypass surgery, or inability to vascularize
resulting in amputation. He understands these risks and agrees to the
procedures.
RADIOGRAPHIC FINDINGS:
1. Aortogram with patent right renal artery. Left renal artery not
visualized. Distal aorta with no significant stenosis. Approximately
50% right common iliac stenosis. Patent right common femoral and
profunda femoris.
2. Occluded right superficial femoral and popliteal arteries.
3. Patent proximal right anterior tibial artery with distal occlusion
at the level of the ankle. Occluded right peroneal and posterior
tibial arteries.
4. No significant runoff to right foot.
DESCRIPTION OF PROCEDURES:
The patient was brought to the operating room. There was concern due to
his age that general anesthesia would be required. However, monitored
anesthetic care was administered. The bilateral groins were sterilely
prepped and draped. A time out procedure was performed. The left groin
was anesthetized with 1% lidocaine.
The left common femoral artery was punctured using a micropuncture
technique. A .035 guidewire was placed in the abdominal aorta. A 5-
French sheath was placed in the right groin. An Omni catheter was placed
into the abdominal aorta, and a flush aortogram was performed. A Swan-
Ganz catheterization was then performed. Multiple pelvic views were
obtained due to a moderate stenosis of the right common iliac artery.
However, this appeared to be an approximately 50% stenosis, and no
intervention was required. A Swan-Ganz catheterization was then performed
to the level of the distal right external iliac artery.
Elective angiogram was then performed of the right lower extremity.
Findings are listed above. No intervention was deemed appropriate. The
future care will require medical management of his wound and chronic pain.
Further revascularization is not possible due to poor runoff. The
catheter was then removed. The left 5-French sheath was removed over a
guidewire.
A percutaneous closure was performed using an Angio-Seal device. There
was no evidence of active bleeding or extension hematoma upon completion.
Thank you in advance.
