Wiki Diagnosis for Cath

[bennieyoung]

I am being audited and questioned on the diagnosis I used when coding the attached report. I would really appreciate if someone could read the report and tell me their choice of diagnosis. I need to know if I have a leg to stand on to rebutt her findings.

CARDIAC CATHETERIZATION REPORT

INDICATIONS FOR PROCEDURE:
1. Known coronary atherosclerosis.
2. Recent onset CCS class II angina.

PROCEDURES:
Left Heart Catheterization, Coronary Angiography, Left Ventriculography

VASCULAR ACCESS:
Initial attempt at right radial access unsuccessful. Switched to right femoral approach. Because of significant aortic tortuosity, a 45 cm braided sheath was used.

CATHETERS:
(1) JL4
(2) JR4
(3) Pigtail

DIAGNOSTIC FINDINGS:

Hemodynamics:
- Aorta: 129/87/69 mmHg
- Left ventricle: 132/22 mmHg
- No aortic valve gradient.

Coronary angiography:
- Left Main: Mild disease; approx 20% stenosis.
- LAD: Diffuse mild-to-moderate proximal disease with 100% occlusion mid and right-to-left collateral filling.
- LCX: Diffuse mild irregularities proximal and mid. Principal, multibranched OM with disease up to 50% proximal.
- RCA: Diffuse mild disease proximal to mid with 50% mid stenosis. PLB system with proximal, high-grade disease up to 80%.

Left ventriculogram:
- LV ejection fraction: 60%
- Wall Motion: Normal

COMPLICATIONS:
None

CONCLUSIONS:
1. Coronary artery disease as described above.
2. Normal LV function.

Will get echo to assess for any valvular heart disease.
Will arrange appt with CT surgery to discuss CABG.

Thank you in advance for any help you can give me with this!

 

[nickelclaw]

I25.118 CAD with angina other form
code the 100 percent occlusion I25.82 this code has a code first note for CAD therefore; make I25.118 primary
Tortuous aorta Q25.46

 

[bennieyoung]

I25.118 CAD with angina other form
code the 100 percent occlusion I25.82 this code has a code first note for CAD therefore; make I25.118 primary
Tortuous aorta Q25.46

I had used I25.119 but the auditor wanted me to use I25.118. I didn't see stable angina and it was stated no stenocardia so I wanted another opinion. Thanks so much for your help!

 

[nickelclaw]

Your welcome per the indications pt already had CAD but now has stage 2 angina therefore other angina I25.118. Remember to always try to not use NOS or unspecified if there is an option for other. Per guidelines code to the most specific code

 

[bennieyoung]

Your welcome per the indications pt already had CAD but now has stage 2 angina therefore other angina I25.118. Remember to always try to not use NOS or unspecified if there is an option for other. Per guidelines code to the most specific code

Thank you so much!