I have a question, based on this description of the procedure would it be ok to bill
CPT 93458..
If not, then can someone please help me in explaining what is it that the Doctor is not mentioning in his description..
PROCEDURE:
1. Left heart catheterization and angiography.
2. Left ventriculography.
CONCLUSION:
1. A 2 vessel coronary artery disease and significant left main
disease, normal left main 60% disease.
2. LAD 100% proximal, with a 60% sequential lesion, aneurysmal and
ectatic vessel.
3. Circumflex normal.
4. RCA 80% proximal stenosis.
5. Ejection fraction 60%.
PLAN
A 3-vessel bypass surgery. Carotid duplex to be checked.
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old gentleman
who presented to an outside facility with increasing shortness of
breath, diaphoresis, left jaw/ear pain, had a stress echocardiogram
with anteroseptal hypokinesis at California Medical Center, was
transferred here for cardiac catheterization and further evaluation.
PROCEDURE NOTE: Informed consent was obtained from the patient. The
patient was premedicated and brought to the cath lab where he was
sterilely prepped and draped and locally anesthetized. The right
femoral artery was cannulated using the Seldinger technique and a 6-
French Hemaquet inserted. Thereafter, over a J-wire, a 6-French JL4
catheter advanced into the left coronary artery. Selective
angiography was performed. This was exchanged over the wire for a JR4
catheter and selective angiography was performed. This was exchanged
for a pigtail catheter, advanced to the left ventricle. Left
ventricular pressures were obtained and left ventriculogram was
performed. The procedure was tolerated without complications. The
sheath was removed and an Angio-Seal device was deployed
successfully.
LEFT VENTRICULOGRAM: Was performed RAO projection with 30 mL of
contrast. The left ventricle function shows normal ejection fraction
65% with no evidence of AV gradient. Left ventricular pressure is
175/3/28 mmHg. Post-ventriculogram 175/4/20 mmHg, consistent with
diastolic dysfunction. The patient received hydralazine 10 mg IV push
in light of hypertension out of control.
CORONARY ANGIOGRAM:
1. Left main normal 60% proximal disease.
2. LAD. Left anterior descending artery is a medium-sized vessel,
courses around the apex. The proximal area is ectatic aneurysmal.
There is a 70% to 80% proximal disease and 50% sequential lesion.
3. Circumflex artery is a medium size vessel, terminates in the
posterior descending artery. Posterior circumflex artery is a medium-
sized vessel. There is no evidence of disease.
4. RCA. The right coronary artery is a moderate size vessel with 80%
proximal disease.
CPT 93458..
If not, then can someone please help me in explaining what is it that the Doctor is not mentioning in his description..
PROCEDURE:
1. Left heart catheterization and angiography.
2. Left ventriculography.
CONCLUSION:
1. A 2 vessel coronary artery disease and significant left main
disease, normal left main 60% disease.
2. LAD 100% proximal, with a 60% sequential lesion, aneurysmal and
ectatic vessel.
3. Circumflex normal.
4. RCA 80% proximal stenosis.
5. Ejection fraction 60%.
PLAN
A 3-vessel bypass surgery. Carotid duplex to be checked.
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old gentleman
who presented to an outside facility with increasing shortness of
breath, diaphoresis, left jaw/ear pain, had a stress echocardiogram
with anteroseptal hypokinesis at California Medical Center, was
transferred here for cardiac catheterization and further evaluation.
PROCEDURE NOTE: Informed consent was obtained from the patient. The
patient was premedicated and brought to the cath lab where he was
sterilely prepped and draped and locally anesthetized. The right
femoral artery was cannulated using the Seldinger technique and a 6-
French Hemaquet inserted. Thereafter, over a J-wire, a 6-French JL4
catheter advanced into the left coronary artery. Selective
angiography was performed. This was exchanged over the wire for a JR4
catheter and selective angiography was performed. This was exchanged
for a pigtail catheter, advanced to the left ventricle. Left
ventricular pressures were obtained and left ventriculogram was
performed. The procedure was tolerated without complications. The
sheath was removed and an Angio-Seal device was deployed
successfully.
LEFT VENTRICULOGRAM: Was performed RAO projection with 30 mL of
contrast. The left ventricle function shows normal ejection fraction
65% with no evidence of AV gradient. Left ventricular pressure is
175/3/28 mmHg. Post-ventriculogram 175/4/20 mmHg, consistent with
diastolic dysfunction. The patient received hydralazine 10 mg IV push
in light of hypertension out of control.
CORONARY ANGIOGRAM:
1. Left main normal 60% proximal disease.
2. LAD. Left anterior descending artery is a medium-sized vessel,
courses around the apex. The proximal area is ectatic aneurysmal.
There is a 70% to 80% proximal disease and 50% sequential lesion.
3. Circumflex artery is a medium size vessel, terminates in the
posterior descending artery. Posterior circumflex artery is a medium-
sized vessel. There is no evidence of disease.
4. RCA. The right coronary artery is a moderate size vessel with 80%
proximal disease.