Annie Posted Tue 22nd of March, 2016 17:38:18 PM
I am having problems coding this. I have coded cardiac caths but it never had the CABG angiogram with it.
PREOPERATIVE DIAGNOSIS: Dilated cardiomyopathy with abnormal stress test,
coronary artery disease, status post coronary artery bypass graft, status
post coronary stent with abnormal stress test, abnormal EKG..
POSTOPERATIVE DIAGNOSIS: Total occlusive native LAD disease with patent
LIMA to LAD. Moderate in-stent stenosis in right coronary artery with
moderate disease otherwise, mild circumflex coronary artery disease with
severe LV systolic dysfunction with global hypokinesis.
OPERATION: Left heart catheterization. Left coronary angiogram. Right
coronary angiogram. Left ventriculogram. CABG graft angiogram.
LOCAL ANESTHESIA: 1% Lidocaine. Conscious sedation with 1.5 mg of IV
PROCEDURE IN DETAIL: After obtaining informed consent, explaining in great
length about the risks, benefits, alternatives of cardiac catheterization,
coronary angiogram, local anesthesia with lidocaine, moderate conscious
sedation and local groin complications, the patient was brought to the
cardiac catheterization laboratory in fasting state. Using sterile
precautions and techniques and with standard protocol, the patient was
prepped and draped in aseptic fashion. Using modified Seldinger technique
a 5-French sheath was placed in right femoral artery over guidewire without
difficulty. A 5-French JL-4 catheter was used for the left coronary
angiogram. A 5-French 3DRC catheter was used for the right coronary
angiogram and also LIMA/graft angiogram. A 5-French pigtail catheter was
used for the left ventriculogram. Multiple views were taken at different
angles. At the end of the procedures all the catheter sheaths were removed
without any difficulty and without any complications. Overall well
tolerated the procedure and does not have any complaints. Vitals were
monitored throughout the procedure and remained stable. The patient was
transferred to the holding area in stable condition.
HEMODYNAMIC RESULTS: Opening aortic pressure was 128/74, left ventricular
end-diastolic pressure was 21 mmHg.
CORONARY ANGIOGRAM FINDINGS: Left main appears normal, divides into left
anterior descending and left circumflex coronary artery system. Left
circumflex coronary artery is a large vessel with tortuosity and mild
disease around 30% in mid segment. Obtuse marginal one and two appears
angiographically normal. Left anterior descending coronary artery has
total occlusive disease in the mid segment and also noted competitive flow
in mid left anterior descending coronary artery. Diagonal one appears with
mild disease only. Some collaterals were noted, left to left coronary
artery system, left to right coronary artery system as well. Right
coronary artery has mild to moderate diffuse disease with long, appears to
be multiple stents, in the proximal to mid segment with at least moderate
in-stent stenosis around 40-50% post stenotic nonobstructive disease around
40% was noted as well. Left internal mammary artery graft to LAD appears
patent. Left ventriculogram shows severe LV systolic dysfunction with
severe dilatation of left ventricle with severe global hypokinesis.
Ejection fraction is around 15%.
IMPRESSION: Patent LIMA to mid LAD with total occlusive disease in the mid
LAD segment. Moderate in-stent stenosis in right coronary artery. Left
circumflex coronary artery system appears with mild disease only, without
any significant obstructive disease. Severe LV systolic dysfunction with
severe global hypokinesis consistent with severe dilated cardiomyopathy.
SUGGESTIONS: Aggressive coronary artery disease risk factors modification,
control and optimization of medical management. I will discuss with
cardiac intervention, although appears medical management is appropriate
for this patient, and will consider defibrillator once the patient agrees.
Until then continue to optimize medications.
SuperCoder Answered Wed 23rd of March, 2016 01:01:34 AM
“AAE does not provide coding for operative reports and chart notes.
SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail email@example.com for more information.’