nancyleephillips
Contributor
Can someone please let me know what codes (ICD-9 and CPT) you would use for this scenario. I would like to check my coding since I have never done a heart cath before.
Thanks!!!!
INDICATION FOR PROCEDURE: A middle-aged male with a history of exertional angina.
PREOPERATIVE DIAGNOSIS(ES):
Crescendo angina.
PROCEDURE:
Left heart catheterization.
Coronary angiography.
Left ventriculography.
Right femoral arteriography.
PROCEDURE: After proper informed consent was obtained, the patient was premedicated with 5 mg of oral diazepam and 25 mg of Benadryl and was transferred to the cardiac catheterization laboratory where while under sterile conditions, the right and left femoral areas were draped and prepped in the usual fashion.
Using 1% Xylocaine solution, adequate anesthesia was obtained. Using an 18-gauge straight needle, the right femoral artery was entered. Using exchange wire technique, a 6 French sheath was advanced into the right femoral artery. Through this sheath using exchange wire technique, a Judkins left #4, 6French catheter was used for left coronary anatomy, a Judkins right #4, 6 French catheter was used for the right coronary anatomy, and a 6 angled French pigtail was used for ventriculography.
Following determination of hemodynamic assessment and coronary angiography, the patient underwent an interventional procedure.
Total sedation given during the procedure was 3 mg of intravenous Versed and 50 mcg of fentanyl.
HEMODYNAMICS: The central aortic pressure was 138/78. The left ventricular pressure was 138/10. There was no gradient across the aortic valve.
VENTRICULOGRAPHY: Ventriculography was obtained in the RAO projection and revealed normal contractility of all left ventricular myocardial segments. The ejection fraction was calculated at greater than 65%.
ANGIOGRAPHY: The left main gave rise to the left anterior descending artery and the left circumflex branch. The left main was free of any significant disease. The left anterior descending artery had sequential lesions of approximately 70%. The circumflex artery was nondominant and it was free of any significant disease. The right coronary was a very large vessel, dominant, and was free of any significant disease.
CONCLUSIONS:
1. Single-vessel coronary disease.
Normal left ventricular function.
Normal hemodynamics.
DISCUSSION: The patient will undergo catheter-based intervention of the left anterior descending lesion.
Thanks!!!!
INDICATION FOR PROCEDURE: A middle-aged male with a history of exertional angina.
PREOPERATIVE DIAGNOSIS(ES):
Crescendo angina.
PROCEDURE:
Left heart catheterization.
Coronary angiography.
Left ventriculography.
Right femoral arteriography.
PROCEDURE: After proper informed consent was obtained, the patient was premedicated with 5 mg of oral diazepam and 25 mg of Benadryl and was transferred to the cardiac catheterization laboratory where while under sterile conditions, the right and left femoral areas were draped and prepped in the usual fashion.
Using 1% Xylocaine solution, adequate anesthesia was obtained. Using an 18-gauge straight needle, the right femoral artery was entered. Using exchange wire technique, a 6 French sheath was advanced into the right femoral artery. Through this sheath using exchange wire technique, a Judkins left #4, 6French catheter was used for left coronary anatomy, a Judkins right #4, 6 French catheter was used for the right coronary anatomy, and a 6 angled French pigtail was used for ventriculography.
Following determination of hemodynamic assessment and coronary angiography, the patient underwent an interventional procedure.
Total sedation given during the procedure was 3 mg of intravenous Versed and 50 mcg of fentanyl.
HEMODYNAMICS: The central aortic pressure was 138/78. The left ventricular pressure was 138/10. There was no gradient across the aortic valve.
VENTRICULOGRAPHY: Ventriculography was obtained in the RAO projection and revealed normal contractility of all left ventricular myocardial segments. The ejection fraction was calculated at greater than 65%.
ANGIOGRAPHY: The left main gave rise to the left anterior descending artery and the left circumflex branch. The left main was free of any significant disease. The left anterior descending artery had sequential lesions of approximately 70%. The circumflex artery was nondominant and it was free of any significant disease. The right coronary was a very large vessel, dominant, and was free of any significant disease.
CONCLUSIONS:
1. Single-vessel coronary disease.
Normal left ventricular function.
Normal hemodynamics.
DISCUSSION: The patient will undergo catheter-based intervention of the left anterior descending lesion.
