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documention for 93306

  1. Default documention for 93306
    Medical Coding Books
    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.

  2. #2
    Jacksonville Florida
    This is how one of my doctors dictates:

    CHF. Mitral valve replacement. Pulmonary hypertension.

    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.

    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

    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.

    Jammie, CPC

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