mcauffman86
Networker
I need some advice on the coding of the following report. I know this documentation does not represent a full Comprehensive EP study, but what can code for, if anything at all???
Preprocedure diagnosis: wide complex tachycardia
Post procedure diagnosis: vt
Indication: wct
Immediate complications: none
Procedure performed:
1) Comprehensive Baseline Electrophysiology Study with His bundle recording and electroanatomic mapping
2) Ultrasound guided venous access
DESCRIPTION OF PROCEDURE:
It was my pleasure to see ************ here for the first time at the EP lab. As you recall, *********** is a 85 year old female with a history of wide complex tachycardia
Risks and benefits of the procedure were discussed in great detail both in clinic and prior to the procedure. Risks described included that of bleeding, infection, cardiac tamponade, stroke, vascular injury requiring surgery as well as death just to name a few. Despite this, the patient was motivated to proceed.
Patient arrived to the EP laboratory in the standard postabsorptive, nonsedated state.
Conscious sedation was administered.
Right femoral venous was obtained and a single catheter was placed in the right atrium.
Vt was immediately diagnosed with more ventricular egms than atrial egms.
At this point, we attempted to terminate the tachcyardia. Cl of the VT was 530. Burst Pacing at 500 ms did not terminate the VT but pacing at 450 ms did.
Ah was 80 and hv was measured at 60 ms
A figure of eight stitch was then placed over the right femoral access site
Preprocedure diagnosis: wide complex tachycardia
Post procedure diagnosis: vt
Indication: wct
Immediate complications: none
Procedure performed:
1) Comprehensive Baseline Electrophysiology Study with His bundle recording and electroanatomic mapping
2) Ultrasound guided venous access
DESCRIPTION OF PROCEDURE:
It was my pleasure to see ************ here for the first time at the EP lab. As you recall, *********** is a 85 year old female with a history of wide complex tachycardia
Risks and benefits of the procedure were discussed in great detail both in clinic and prior to the procedure. Risks described included that of bleeding, infection, cardiac tamponade, stroke, vascular injury requiring surgery as well as death just to name a few. Despite this, the patient was motivated to proceed.
Patient arrived to the EP laboratory in the standard postabsorptive, nonsedated state.
Conscious sedation was administered.
Right femoral venous was obtained and a single catheter was placed in the right atrium.
Vt was immediately diagnosed with more ventricular egms than atrial egms.
At this point, we attempted to terminate the tachcyardia. Cl of the VT was 530. Burst Pacing at 500 ms did not terminate the VT but pacing at 450 ms did.
Ah was 80 and hv was measured at 60 ms
A figure of eight stitch was then placed over the right femoral access site