Question Diagnosis Coding1


Broomfield, CO
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I used I25.119 and Z87.891 I didn't add N-stemi because the discharge summary stated the cause was uncertain but he did not have evidence of acute coronary episode. Would someone read the note and let me know how you would have done it?
1. Nonselective right groin sheathogram.
2. Bilateral angiography, left heart catheterization and left ventriculogram.
3. Saphenous vein angiography to diagonal artery.
4. Saphenous vein angiography to left posterior descending artery.
5. Left internal mammary artery angiography to left anterior descending artery.

BRIEF HISTORY: Briefly, this is a 90-year-old male with a history of CABG, TAVR. The patient was admitted for chest pain and elevated troponin levels. The patient was consented for cardiac catheterization.

DESCRIPTION OF PROCEDURE: After informed consent, the patient was brought to BCH, where the right groin was prepped and draped in standard fashion. Using lidocaine, a short 6-French sheath was introduced into the right common femoral artery and verified angiographically. The 0.035 wire was advanced. The wire entered easily into the left ventricle. Thus, we decided to place a pigtail catheter into the left ventricle. EDP was a 6 mmHg. Left ventriculogram obtained in the RAO projection showed EF of 65% with no wall motion abnormalities. No pullback gradient between the LV and the aorta. The JL3.5 catheter was then advanced into the left coronary artery. Images of the left coronary artery revealed a short left main. The LAD had 90% proximal disease, and it was subtotally occluded after the septal perforator takeoff. The left circumflex artery had mild 30% disease proximally. There was a marginal-1 artery, which was previously stented, which was widely patent. In the midbody of the left circumflex artery, there was tubular 40% disease, which was present on prior catheterization. There was a marginal-2 artery, which appeared to be healthy and free of disease. There appeared to be a complete occlusion of the circ distally, which most likely represents LPDA. After the images had been obtained, the JL4 catheter was removed. The JR4 catheter was advanced into the right coronary artery. Images of the right coronary artery revealed a nondominant RCA with 70% proximal RCA disease. The superior RV marginal branch had what appeared to be 90% tubular disease. Again, this was a nondominant vessel and these lesions were seen on prior angiograms. JR4 catheter was then pulled back to the first graft, which was the graft to the diagonal-1 artery which had mild aneurysmal disease proximally, but it was widely patent and anastomosing to a diagonal artery, which was patent distally. After these images were obtained, the JR4 catheter was switched out for a LIMA catheter. Angiography of the left internal mammary artery showed widely patent LIMA anastomosing to the mid-LAD. The distal LAD appeared to be widely patent and free of disease. The LIMA catheter was then removed. A multipurpose catheter was then advanced, and images of the graft to the LPDA was obtained which showed widely patent saphenous vein graft anastomosing to the LPDA, which appeared to be widely patent. After these images were obtained, the multipurpose catheter was removed. The right groin was sutured in place. The patient tolerated the procedure well with no complications.

1. Severe native coronary artery disease.
2. Widely patent saphenous vein graft to diagonal artery, saphenous vein graft to left anterior descending artery, and left internal mammary artery to left anterior descending artery.
3. Normal ejection fraction with no significant gradient across the transcatheter aortic valve replacement valve.

PLAN: The patient's coronary artery disease is unchanged since his last angiogram approximately 1 year ago. His stent is widely patent at his marginal artery. His EF is normal as is the gradients across the valve. Suspect his chest pain may be due to new onset atrial fibrillation, which was noted on his pacemaker interrogation yesterday. We will institute Eliquis low-dose 2.5 b.i.d. in addition to his Plavix. Would hold the aspirin at this point.

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