LHC with Bilat Renal Angio Report

em2177

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311
Location
San Gabriel Valley,CA
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Need some assistance in coding this report. I have 93452,26,59/36245,50,59/75724,26. Is this correct?

Thank You!

HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old female who has had
progressive increasing chest discomfort. The patient comes in with severe
hypertension. The patient does have a history of hyperlipidemia and diabetes.
The patient did not respond well to blood pressure medications. The patient
has had this longstanding. The patient denies any history of heart attack or
stroke. The patient is requiring high-dose Cardene drip in order to control
her blood pressure as well as chest discomfort. Thus, the patient has been
explained the risks, benefits, and alternatives of left heart catheterization
plus/minus angioplasty and stenting. The patient has also had an ultrasound
concerning for renal artery stenosis. Thus, she and her family have been
explained the risks, benefits, and alternatives for selective renal angiography
plus/minus angioplasty and stenting. The patient and her family agreed to
proceed.

PROCEDURE: The patient was brought to the catheterization lab and prepped and
draped in a sterile fashion. Lidocaine was placed to the right common femoral
area. A 6-French sheath was placed to the right common femoral artery using
Seldinger technique. Angiography of the groin site confirmed common femoral
arterial placement.
Next left heart catheterization was performed with a JL4 with multiple-view
angiography followed by a JR4 with angiography of the right system. The JR4
was then used to be selectively engaged under fluoroscopic guidance the left
renal artery, and angiography was performed followed by selective angiography
of the right renal artery. The JR4 was removed. A pigtail was placed across
the aortic valve measuring an LVEDP of 10. LV angiography was performed with
also visualization of the aorta, and then pullback revealed no significant
aortic valve gradient.
Angio-Seal was placed to the right common femoral artery using standard
technique with good groin hemostasis and no evidence of oozing, bruising, or
hematoma.

IMPRESSION:
1. Left main shows no disease.
2. The LAD and diagonals, a very large branch, shows no evidence of disease.
3. The left circumflex has a large obtuse marginal with no disease.
4. The RCA is a very large dominant vessel with no disease.
5. LVEDP of 10.
6. LVEF of 70% to 75% with no wall motion abnormality and no evidence of
mitral regurgitation.
7. No aortic valve gradient.
8. Normal-sized aorta with no evidence of dissection.
9. Bilateral selective renal angiography shows less than 10% stenosis with no
dampening on a gradient with selective engagement with the JR4.
Postprocedure, the patient tolerated the procedure well and remained
hemodynamically stable. Systolic blood pressure was in the 140s with Cardene
drip. Thus at this time, I will optimize medical therapy, and we will continue
to closely follow with alternative causes for malignant hypertension.
 

dpeoples

True Blue
Messages
889
Location
Birmingham, Alabama
Best answers
0
Need some assistance in coding this report. I have 93452,26,59/36245,50,59/75724,26. Is this correct?

Thank You!

HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old female who has had
progressive increasing chest discomfort. The patient comes in with severe
hypertension. The patient does have a history of hyperlipidemia and diabetes.
The patient did not respond well to blood pressure medications. The patient
has had this longstanding. The patient denies any history of heart attack or
stroke. The patient is requiring high-dose Cardene drip in order to control
her blood pressure as well as chest discomfort. Thus, the patient has been
explained the risks, benefits, and alternatives of left heart catheterization
plus/minus angioplasty and stenting. The patient has also had an ultrasound
concerning for renal artery stenosis. Thus, she and her family have been
explained the risks, benefits, and alternatives for selective renal angiography
plus/minus angioplasty and stenting. The patient and her family agreed to
proceed.

PROCEDURE: The patient was brought to the catheterization lab and prepped and
draped in a sterile fashion. Lidocaine was placed to the right common femoral
area. A 6-French sheath was placed to the right common femoral artery using
Seldinger technique. Angiography of the groin site confirmed common femoral
arterial placement.
Next left heart catheterization was performed with a JL4 with multiple-view
angiography followed by a JR4 with angiography of the right system. The JR4
was then used to be selectively engaged under fluoroscopic guidance the left
renal artery, and angiography was performed followed by selective angiography
of the right renal artery. The JR4 was removed. A pigtail was placed across
the aortic valve measuring an LVEDP of 10. LV angiography was performed with
also visualization of the aorta, and then pullback revealed no significant
aortic valve gradient.
Angio-Seal was placed to the right common femoral artery using standard
technique with good groin hemostasis and no evidence of oozing, bruising, or
hematoma.

IMPRESSION:
1. Left main shows no disease.
2. The LAD and diagonals, a very large branch, shows no evidence of disease.
3. The left circumflex has a large obtuse marginal with no disease.
4. The RCA is a very large dominant vessel with no disease.
5. LVEDP of 10.
6. LVEF of 70% to 75% with no wall motion abnormality and no evidence of
mitral regurgitation.
7. No aortic valve gradient.
8. Normal-sized aorta with no evidence of dissection.
9. Bilateral selective renal angiography shows less than 10% stenosis with no
dampening on a gradient with selective engagement with the JR4.
Postprocedure, the patient tolerated the procedure well and remained
hemodynamically stable. Systolic blood pressure was in the 140s with Cardene
drip. Thus at this time, I will optimize medical therapy, and we will continue
to closely follow with alternative causes for malignant hypertension.
Assuming the date of service was in 2012:

93458
36252

75724 is not a valid code in 2012.

HTH :)
 
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