Bernadette10
Guru
Should both the preop and postop diagnoses be coded for a transesophageal echocardiogram that was done in the OR for an aortic valve replacement?
Code the aortic valve calcification and stenosis I35.0, I35.8 and the valve replacement Z95.2 or just Z95.2 alone?
I'm thinking all should be coded but am not sure - I35.0, I35.8, I51.7, Z95.2
Indications: Coronary artery disease, severe aortic stenosis
Technical Quality/Procedure: The study images were of good quality. Intraoperative TEE was used to (1) evaluate cardiac and valvular function to assist in surgical & clinical decision-making (2) help guide cardiopulmonary bypass cannulation; (3) facilitate surveillance of cardiac function; (4) evaluate surgical repair. A complete transesophageal echocardiogram was performed in the O.R. for immediate pre-operative and post-operative evaluation of cardiac function and valvular heart disease during cardiac surgery. Images repeated after patient was weaned from CPB.
Conclusions:
Pre-Bypass Exam:
1. Normal left ventricular size. Left ventricular systolic function is normal. The left ventricular ejection fraction by visual assessment is estimated to be 55-60 %. The left ventricular wall motion
is normal. Mild left ventricular hypertrophy.
2. Normal right ventricular size. Normal right ventricular systolic function.
3. The aortic cusps appear moderately thickened. The aortic valve is severely calcified. There is severe aortic stenosis. There is trace aortic regurgitation.
Post-Bypass Exam:
S/P Valve replacement, Aortic (AVR) - Full sternotomy aortic valve replacement, Bioprosthetic - Medtronic: Avalus Size 25, CABG x 1: Arterial graft x 1
1. Post-Bypass Intotrophic/vasoactive support in the form of epinephrine was used.
2. Normal left ventricular size. Left ventricular systolic function is normal. The left ventricular ejection fraction by visual assessment is estimated to be 60-65 %. The left ventricular wall motion
is normal.
3. Normal right ventricular size. Normal right ventricular systolic function.
4. The aortic valve has been replaced. There is a 25 mm Avalus bioprosthetic valve in the aortic position. The valve is well seated with no paravalvular leak. The mean transvalvular gradient is 6 mm
Hg.
5. No evidence of aortic dissection after decannulation.
Pre-Procedural Findings
Left Ventricle: Normal left ventricular size. Mild left ventricular hypertrophy. Left ventricular systolic function is normal. The left ventricular ejection fraction by visual assessment is
estimated to be 55-60 %. The left ventricular wall motion is normal.
Right Ventricle: Normal right ventricular size. Normal right ventricular systolic function.
Atria/ Interatrial septum:
The left atrium is normal in size.
The left atrial appendage is normal in appearance with no evidence of thrombus.
Pulsed wave Doppler of the left atrial appendage demonstrates normal emptying velocity.
The right atrium is of normal size.
The interatrial septum is thin and hypermobile.
No Interatrial septum shunt visualized by color doppler.
There is moderate lipomatous hypertrophy of the atrial septum.
Mitral Valve: Mitral valve leaflets appear mildly thickened. Mild mitral annular calcification. No evidence of mitral stenosis. There is trace mitral regurgitation.
Tricuspid Valve: The tricuspid valve is normal. There is no evidence of tricuspid regurgitation. There is no evidence of tricuspid stenosis.
Aortic Valve: The aortic cusps appear moderately thickened. The aortic valve is severely calcified. There is severe aortic stenosis. There is trace aortic regurgitation.
Pulmonic Valve: The pulmonic valve appears to be normal. There is no evidence of pulmonic valve regurgitation.
Arteries/Veins:
The aortic root is of normal size.
The ascending aorta is normal in size.
Aortic arch normal in size.
The aortic cardiopulmonary bypass cannula tip was visualized in the aortic arch; test infusion confirmed intraluminal position..
The venous CPB cannula was visualized, good position in the hepatic IVC.
A LV vent catheter visualized, positioned in the LV cavity and across mitral valve.
Pericardium/Pleural space:
Normal pericardium with no pericardial effusion..
No pleural effusions visualized.
Post-Procedural Findings
Left Ventricle: Normal left ventricular size. Left ventricular systolic function is normal. The left ventricular ejection fraction by visual assessment is estimated to be 60-65 %. The left
ventricular wall motion is normal.
Right Ventricle: Normal right ventricular size. Normal right ventricular systolic function.
Atria/ Interatrial septum:
Left atrium appears unchanged post procedural.
Right atrium appears unchanged post procedural.
Interatrial septum appears unchanged post procedural.
No Interatrial septum shunt visualized by color doppler.
Mitral Valve: Mitral valve appears unchanged post procedural. No evidence of mitral stenosis. There is trace mitral regurgitation.
Tricuspid Valve: Tricuspid valve appears unchanged post procedural. There is no evidence of tricuspid regurgitation. There is no evidence of tricuspid stenosis.
Aortic Valve: The aortic valve has been replaced. There is a 25 mm Avalus bioprosthetic valve in the aortic position. The valve is well seated with no paravalvular leak. The mean transvalvular
gradient is 6 mm Hg.
Pulmonic Valve: Pulmonic valve appears unchanged post procedural. There is no evidence of pulmonic valve regurgitation.
Arteries/Veins:
No evidence of aortic dissection after decannulation.
Pericardial/Pleural space:
No pleural effusions visualized.
Normal pericardium with no pericardial effusion..
Code the aortic valve calcification and stenosis I35.0, I35.8 and the valve replacement Z95.2 or just Z95.2 alone?
I'm thinking all should be coded but am not sure - I35.0, I35.8, I51.7, Z95.2
Indications: Coronary artery disease, severe aortic stenosis
Technical Quality/Procedure: The study images were of good quality. Intraoperative TEE was used to (1) evaluate cardiac and valvular function to assist in surgical & clinical decision-making (2) help guide cardiopulmonary bypass cannulation; (3) facilitate surveillance of cardiac function; (4) evaluate surgical repair. A complete transesophageal echocardiogram was performed in the O.R. for immediate pre-operative and post-operative evaluation of cardiac function and valvular heart disease during cardiac surgery. Images repeated after patient was weaned from CPB.
Conclusions:
Pre-Bypass Exam:
1. Normal left ventricular size. Left ventricular systolic function is normal. The left ventricular ejection fraction by visual assessment is estimated to be 55-60 %. The left ventricular wall motion
is normal. Mild left ventricular hypertrophy.
2. Normal right ventricular size. Normal right ventricular systolic function.
3. The aortic cusps appear moderately thickened. The aortic valve is severely calcified. There is severe aortic stenosis. There is trace aortic regurgitation.
Post-Bypass Exam:
S/P Valve replacement, Aortic (AVR) - Full sternotomy aortic valve replacement, Bioprosthetic - Medtronic: Avalus Size 25, CABG x 1: Arterial graft x 1
1. Post-Bypass Intotrophic/vasoactive support in the form of epinephrine was used.
2. Normal left ventricular size. Left ventricular systolic function is normal. The left ventricular ejection fraction by visual assessment is estimated to be 60-65 %. The left ventricular wall motion
is normal.
3. Normal right ventricular size. Normal right ventricular systolic function.
4. The aortic valve has been replaced. There is a 25 mm Avalus bioprosthetic valve in the aortic position. The valve is well seated with no paravalvular leak. The mean transvalvular gradient is 6 mm
Hg.
5. No evidence of aortic dissection after decannulation.
Pre-Procedural Findings
Left Ventricle: Normal left ventricular size. Mild left ventricular hypertrophy. Left ventricular systolic function is normal. The left ventricular ejection fraction by visual assessment is
estimated to be 55-60 %. The left ventricular wall motion is normal.
Right Ventricle: Normal right ventricular size. Normal right ventricular systolic function.
Atria/ Interatrial septum:
The left atrium is normal in size.
The left atrial appendage is normal in appearance with no evidence of thrombus.
Pulsed wave Doppler of the left atrial appendage demonstrates normal emptying velocity.
The right atrium is of normal size.
The interatrial septum is thin and hypermobile.
No Interatrial septum shunt visualized by color doppler.
There is moderate lipomatous hypertrophy of the atrial septum.
Mitral Valve: Mitral valve leaflets appear mildly thickened. Mild mitral annular calcification. No evidence of mitral stenosis. There is trace mitral regurgitation.
Tricuspid Valve: The tricuspid valve is normal. There is no evidence of tricuspid regurgitation. There is no evidence of tricuspid stenosis.
Aortic Valve: The aortic cusps appear moderately thickened. The aortic valve is severely calcified. There is severe aortic stenosis. There is trace aortic regurgitation.
Pulmonic Valve: The pulmonic valve appears to be normal. There is no evidence of pulmonic valve regurgitation.
Arteries/Veins:
The aortic root is of normal size.
The ascending aorta is normal in size.
Aortic arch normal in size.
The aortic cardiopulmonary bypass cannula tip was visualized in the aortic arch; test infusion confirmed intraluminal position..
The venous CPB cannula was visualized, good position in the hepatic IVC.
A LV vent catheter visualized, positioned in the LV cavity and across mitral valve.
Pericardium/Pleural space:
Normal pericardium with no pericardial effusion..
No pleural effusions visualized.
Post-Procedural Findings
Left Ventricle: Normal left ventricular size. Left ventricular systolic function is normal. The left ventricular ejection fraction by visual assessment is estimated to be 60-65 %. The left
ventricular wall motion is normal.
Right Ventricle: Normal right ventricular size. Normal right ventricular systolic function.
Atria/ Interatrial septum:
Left atrium appears unchanged post procedural.
Right atrium appears unchanged post procedural.
Interatrial septum appears unchanged post procedural.
No Interatrial septum shunt visualized by color doppler.
Mitral Valve: Mitral valve appears unchanged post procedural. No evidence of mitral stenosis. There is trace mitral regurgitation.
Tricuspid Valve: Tricuspid valve appears unchanged post procedural. There is no evidence of tricuspid regurgitation. There is no evidence of tricuspid stenosis.
Aortic Valve: The aortic valve has been replaced. There is a 25 mm Avalus bioprosthetic valve in the aortic position. The valve is well seated with no paravalvular leak. The mean transvalvular
gradient is 6 mm Hg.
Pulmonic Valve: Pulmonic valve appears unchanged post procedural. There is no evidence of pulmonic valve regurgitation.
Arteries/Veins:
No evidence of aortic dissection after decannulation.
Pericardial/Pleural space:
No pleural effusions visualized.
Normal pericardium with no pericardial effusion..