MHATRAINING
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Hi! I need assistance coding the following procedure. Thank you in advance.
Procedure:
1. MODERATE IV SEDATION AND MONITORING
2. LEFT HEART CATHETERIZATION
3. CORONARY ANGIOGRAM
4. LEFT VENTRICULAR ANGIOGRAM
5. LIMA ANGIOGRAM
6. SVG ANGIOGRAM
7. MYNX CLOSURE
Preoperative Diagnosis: Abnormal stress test (ICD10-CM R94.39, Discharge, Medical), Exertional angina (ICD10-CM I20.8,
Discharge, Medical), Chronic combined systolic and
diastolic heart failure (ICD10-CM I50.42, Discharge, Medical), CAD (coronary artery disease) (ICD10-CM I25.10, Discharge,
Medical).
Postoperative Diagnosis: Same.
Performed by:
Assistant: N/A.
Anesthesiologist: N/A.
Findings:
MODERATE IV SEDATION WAS ADMINISTERED WHILE THE PATIENT WAS MONITORED CLOSELY.
AFTER 1% LIDOCAINE WAS ADMINISTERED FOR LOCAL ANESTHESIA, A MICROPUNCTURE TECHNIQUE WAS
USED TO ACCESS THE FEMORAL ARTERY AND A 6 FR SHEATH WAS INSERTED. THE JL4/JR4 CATHETERS
WERE USED TO SELECTIVELY CANNULATE THE CORONARY ARTERIES AND LEFT VENTRICLE AND OBTAIN
ANGIOGRAPHIC IMPAGES AND HEMODYNAMIC MEASUREMENTS.
AFTER THE CARDIAC PROCEDURE WAS COMPLETED, A MYNX DEVICE WAS USED TO ACHIEVE HEMOSTASIS.
THE PATIENT TOLERATED THE PROCEDURE WELL AND WAS TRANSFERRED TO THE RECOVERY ROOM IN
STABLE CONDITION.
MODERATE CONSCIOUS SEDATION TIME: 23 MINUTES
HEMODYNAMICS: AORTA 119/66 mmHg, MEAN Ao 89 mmHg, LVEDP 17 mmHg.
FINDINGS:
LM: LARGE, DISTAL SEVERE STENOSIS
LAD: PROXIMAL AND MID SEVERE DIFFUSE DISEASE, MID AND DISTAL LAD HAVE MILD IRREGULARITIES
AND FILL VIA LIMA GRAFT
LCX: NON-DOMINANT, MODERATE SIZE, PROXIMAL AND MID SEVERE DIFFUSE DISEASE, MID AND DISTAL
LCX HAVE MILD IRREGULARITIES AND FILL VIA SVG
RCA: DOMINANT, LARGE, VERY PROXIMAL CTO, DISTAL VESSEL AND RPDA FILL VIA SVG.
LEFT VENTRICLE: EF 35%
LIMA/LAD: WIDELY PATENT
SVG/DISTAL LCX: WIDELY PATENT
SVG/DISTAL RCA: WIDELY PATENT
IMPRESSION:
1. SEVERE 3V NATIVE CAD, ALL GRAFTS PATENT
2. EF 35%
PLAN:
1. OPTIMAL MEDICAL MANAGEMENT OF UNDERLYING CARDIAC RISK FACTORS, KNOWN CAD, AND CHF.
2. LISINOPRIL AND SPIRONOLACTONE ADDED TO HIS DISCHARGE MEDICATIONS.
***
*.
Specimens Removed: None.
Estimated Blood Loss: None.
Anesthesia Type: IV Sedation.
Complications: None.
Procedure:
1. MODERATE IV SEDATION AND MONITORING
2. LEFT HEART CATHETERIZATION
3. CORONARY ANGIOGRAM
4. LEFT VENTRICULAR ANGIOGRAM
5. LIMA ANGIOGRAM
6. SVG ANGIOGRAM
7. MYNX CLOSURE
Preoperative Diagnosis: Abnormal stress test (ICD10-CM R94.39, Discharge, Medical), Exertional angina (ICD10-CM I20.8,
Discharge, Medical), Chronic combined systolic and
diastolic heart failure (ICD10-CM I50.42, Discharge, Medical), CAD (coronary artery disease) (ICD10-CM I25.10, Discharge,
Medical).
Postoperative Diagnosis: Same.
Performed by:
Assistant: N/A.
Anesthesiologist: N/A.
Findings:
MODERATE IV SEDATION WAS ADMINISTERED WHILE THE PATIENT WAS MONITORED CLOSELY.
AFTER 1% LIDOCAINE WAS ADMINISTERED FOR LOCAL ANESTHESIA, A MICROPUNCTURE TECHNIQUE WAS
USED TO ACCESS THE FEMORAL ARTERY AND A 6 FR SHEATH WAS INSERTED. THE JL4/JR4 CATHETERS
WERE USED TO SELECTIVELY CANNULATE THE CORONARY ARTERIES AND LEFT VENTRICLE AND OBTAIN
ANGIOGRAPHIC IMPAGES AND HEMODYNAMIC MEASUREMENTS.
AFTER THE CARDIAC PROCEDURE WAS COMPLETED, A MYNX DEVICE WAS USED TO ACHIEVE HEMOSTASIS.
THE PATIENT TOLERATED THE PROCEDURE WELL AND WAS TRANSFERRED TO THE RECOVERY ROOM IN
STABLE CONDITION.
MODERATE CONSCIOUS SEDATION TIME: 23 MINUTES
HEMODYNAMICS: AORTA 119/66 mmHg, MEAN Ao 89 mmHg, LVEDP 17 mmHg.
FINDINGS:
LM: LARGE, DISTAL SEVERE STENOSIS
LAD: PROXIMAL AND MID SEVERE DIFFUSE DISEASE, MID AND DISTAL LAD HAVE MILD IRREGULARITIES
AND FILL VIA LIMA GRAFT
LCX: NON-DOMINANT, MODERATE SIZE, PROXIMAL AND MID SEVERE DIFFUSE DISEASE, MID AND DISTAL
LCX HAVE MILD IRREGULARITIES AND FILL VIA SVG
RCA: DOMINANT, LARGE, VERY PROXIMAL CTO, DISTAL VESSEL AND RPDA FILL VIA SVG.
LEFT VENTRICLE: EF 35%
LIMA/LAD: WIDELY PATENT
SVG/DISTAL LCX: WIDELY PATENT
SVG/DISTAL RCA: WIDELY PATENT
IMPRESSION:
1. SEVERE 3V NATIVE CAD, ALL GRAFTS PATENT
2. EF 35%
PLAN:
1. OPTIMAL MEDICAL MANAGEMENT OF UNDERLYING CARDIAC RISK FACTORS, KNOWN CAD, AND CHF.
2. LISINOPRIL AND SPIRONOLACTONE ADDED TO HIS DISCHARGE MEDICATIONS.
***
*.
Specimens Removed: None.
Estimated Blood Loss: None.
Anesthesia Type: IV Sedation.
Complications: None.
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