lavernacrowe
New
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- 1
- Location
- Mesa, AZ
This patient came in for an aortic valve replacement, after anesthesia they did the tee, found a mass and cancelled the procedure, would you code the valve replacement with a mod -74 or just the intraoperative tee? It is Medicare.
Pre-operative Diagnosis: Severe aortic valvular stenosis.
Post-operative Diagnosis: Same and cardiac mass discovered on intraoperative transesophageal echocardiogram.
Procedure(s): Intraoperative transesophageal echocardiogram.
Surgeon: Derek Von Haag, MD
Assistant(s): Austin.
Anesthesiologist: Dr. Nathan Herrington
Anesthesia: General endotrachial anesthesia
Indications: See pre-operative history and physical.
Findings: Cardiac mass between pulmonary artery and left atrial appendage discovered on intraoperative transesophageal echocardiogram prior to initiating procedure.
Specimen(s): Not applicable
Estimated Blood Loss: 0
Other: Not applicable
Complications: None.
Description of Procedure: After intubation transesophageal echocardiogram was performed by anesthesia which surprisingly revealed an cardiac mass appearing to originate between the pulmonary artery and left atrial appendage that appeared well-circumscribed and homogeneous approximately 2 cm in diameter. CT scan was reviewed intraoperatively and the mass was not obvious on the CT scan. This likely represents a new mass with differential diagnosis including possible abscess, possible cardiac tumor as well as other possible diagnoses. The case was canceled and cardiac MRI will be ordered and the patient will follow-up with cardiology for further workup of this mass. I will also see the patient and her family in my clinic in follow-up to answer any lingering questions.
Condition: Good
Pre-operative Diagnosis: Severe aortic valvular stenosis.
Post-operative Diagnosis: Same and cardiac mass discovered on intraoperative transesophageal echocardiogram.
Procedure(s): Intraoperative transesophageal echocardiogram.
Surgeon: Derek Von Haag, MD
Assistant(s): Austin.
Anesthesiologist: Dr. Nathan Herrington
Anesthesia: General endotrachial anesthesia
Indications: See pre-operative history and physical.
Findings: Cardiac mass between pulmonary artery and left atrial appendage discovered on intraoperative transesophageal echocardiogram prior to initiating procedure.
Specimen(s): Not applicable
Estimated Blood Loss: 0
Other: Not applicable
Complications: None.
Description of Procedure: After intubation transesophageal echocardiogram was performed by anesthesia which surprisingly revealed an cardiac mass appearing to originate between the pulmonary artery and left atrial appendage that appeared well-circumscribed and homogeneous approximately 2 cm in diameter. CT scan was reviewed intraoperatively and the mass was not obvious on the CT scan. This likely represents a new mass with differential diagnosis including possible abscess, possible cardiac tumor as well as other possible diagnoses. The case was canceled and cardiac MRI will be ordered and the patient will follow-up with cardiology for further workup of this mass. I will also see the patient and her family in my clinic in follow-up to answer any lingering questions.
Condition: Good