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anteroseptal myocardial ischemia - Cardiology section

ohn0disaster

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330
Location
Stuart, Florida
**I posted this in the Diagnosis Coding section of the forum but got no response. I was hoping that maybe someone that follows the Cardiology section may have an opinion for me.**


Ok I'm needing a bit of help with how to code a dx. I pulled pertinent info from the note and left out the "blah blah blah" of it all.

subjective:
patient comes today for followup. eating and sleeping well. no major complaints. no chest pain. no fatigue. no shortness of breath except for when she tries to exert herself then she gets very short-winded. no orthopnea at night. the patient recently had a stress test done and the patient has pending followup with a cardiologist.


final impression:
1) inconclusive lexiscan stress test
2) abnormal myocardial perfusion scan with mild anteroseptal reversible ischemia with an ejection fraction of 57% and clinical correlation was recommended.

final assesment:
anteroseptal myocardial ischemia, pending evaluation by the cardiologist for further followup.
 
"anteroseptal myocardial ischemia, pending evaluation by the cardiologist for further followup"

I can read this statement 2 ways

1) Definitive DX of ischemia---then look at 414.8 (don't have my book in front of me)

2) DX of ischemia pending cardiologist review of test results--- then would code 794.30 for abnormal test
 
What I gather out of the statement is that the cardiologist has already reviewed and stated that the patient has anteroseptal myocardial ischemia. Now the patient will be following up for further care/treatment. Thank you for replying.
 
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