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Does somebody have a sample note for procedure code 93306. One of my doctors that I do billing for has horrible notes. I am trying to help him.
Thanks,
Nancy
INTERPRETATION:
2D and M-Mode evaluation of the cardiac chambers were obtained. Left
ventricular end diastolic and systolic dimensions reveal significantly
enlarged left ventricle. Contractility is preserved with ejection fraction
at about 55%. Left atrium appears to be enlarged. By history, the patient
has a prosthetic mitral valve. There are sclerotic changes noted in the
mitral annulus. There is also sclerosis noted of the aortic valve. The
mitral valve appears to be seated well.
Doppler and color flow evaluation of the valves revealed mild aortic
insufficiency with aortic pressure half time at 930 meters per second. There
is moderate tricuspid regurgitation with estimated right ventricular systolic
pressure of 43 mmHg. There is prosthetic mitral valve functioning well with
a trivial mitral regurgitation noted, probably appropriate for the valve.
MEASUREMENTS -
M-MODE DOPPLER -
NORMAL NORMAL LOCATION VELOCITY
LVIDD 6.5 <5.6 LA 4.7
LVIDS 4.5 <3.5 AO 2.8 2.0-3.8
IVSD 1.1 <1.2 ACS
IVSS 1.3 LVOT
LVPWD 1.2 <1.2 EF 57% Teicholz
LVPWS 1.9 FS
RV <2.6 HR
CONCLUSOIN
Dilated left with a prosthetic mitral valve with preserved left ventricular
function, left atrial enlargement, trivial mitral regurgitation, mild aortic
insufficiency and moderate tricuspid regurgitation, pulmonary hypertension.