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Need some help coding this.....

  1. #1
    Location
    Jacksonville Florida
    Posts
    126
    Question Need some help coding this.....
    Medical Coding Books
    Here's what I got from the report (which is very long, so thank you to everyone that reads it )any suggestions or additional comments would be wonderful

    92980-LC
    33970
    33971
    33210
    71090-26
    93510-26
    93545
    93556-2659
    93543
    93555-2659
    93540

    NAME OF TEST:
    1. Left heart cardiac catheterization.
    2. Coronary angiography.
    3. Left ventriculography.
    4. Saphenous vein bypass graft injection.
    5. Rotational atherectomy with subsequent implantation of four overlapping
    Promus drug-eluding intracoronary stents into the very proximal aspect
    of the left circumflex coronary artery, including its ostium all the
    way down into the distal left circumflex coronary artery.
    6. Insertion of an intraaortic balloon pump via the left femoral artery.
    7. Insertion of a transvenous temporary pacemaker via the left femoral
    vein.

    HISTORY
    The patient is a very pleasant, 62-year-old female with a history of known
    atherosclerotic coronary artery disease. She actually underwent coronary
    artery bypass surgery back several years ago. She had two bypass grafts
    placed at that time. She had a single bypass graft off her aorta which
    bifurcated and one limb went to her left anterior descending and second limb
    went to the obtuse marginal branch of the left circumflex coronary artery.
    At the time of her previous cardiac catheterization two years ago, she was
    noted to have the limb to the obtuse marginal branch to be totally occluded.
    The graft to the left anterior descending was patent. She has a nondominant
    right coronary artery. The patient presented to Baptist Medical Center with
    some GI type symptoms. She subsequently developed an episode of severe chest
    pain after being in the hospital and was noted to have transient ST segment
    elevation in leads 1 and AVL along with marked reciprocal ST segment
    depression in her anterior precordial leads as well as in her inferior leads.
    After stabilization, she was brought to the cardiac catheterization
    laboratory for further evaluation today.

    PROCEDURE
    The patient was brought to the cardiac catheterization laboratory in very
    stable condition. The right groin area was prepped and draped in the usual
    sterile fashion. Using 1% Xylocaine, the right femoral area was
    anesthetized. Using a Cook needle, the right femoral artery was easily
    entered without any difficulty and a 6 French sheath was placed via the
    Seldinger technique. This sheath was aspirated and flushed. Diagnostic
    coronary angiography was then performed utilizing a 6 French 4 left Judkins 5
    French 4 left Judkins catheters in order to inject the patient's left
    coronary artery. It should be noted that the patient had marked dampening
    of pressure when both catheters were inserted. The right coronary artery was
    injected non-selectively with a 4 French 4 Williams right coronary diagnostic
    catheter. The patient was noted to have a small, nondominant right coronary
    artery which supplies very little myocardium from a previous cardiac
    catheterization. Utilizing the same 5 French Williams right coronary
    diagnostic catheter, we were able to manipulate the catheter into the bypass
    graft to the left anterior descending. This saphenous vein bypass graft to
    the left anterior descending was injected.

    We then performed a left ventriculogram in the 30 degree RAO projection
    utilizing a 6 French angled pigtail catheter. This angled pigtail catheter
    was then pulled back across the aortic valve in order to measure any possible
    transaortic valve gradient. Upon reviewing the patient's cineangiograms, it
    was very obvious that the patient had rather pronounced left ventricular
    systolic dysfunction. Her left ventricle appeared to have an ejection
    fraction of approximately 25%. This was clearly worse than it had been on
    previous cardiac catheterization a couple of years ago. She had a patent
    bypass graft to the left anterior descending. Her right coronary artery, as
    mentioned earlier, was a small vessel which was nondominant. The patient had
    severe disease in her proximal left circumflex coronary artery with an 80%
    calcified lesion in the ostial part of the circumflex at its takeoff from the
    left main. In the proximal circumflex, further downstream, there was a 70%
    narrowing noted. In the mid left circumflex coronary artery, there was a 60%
    narrowing noted. In the distal left circumflex coronary artery prior to a
    couple of distal obtuse marginal branches and a posterior descending branch,
    there is a 60% lesion noted.

    After careful review of the patient's cineangiograms, I felt that the best
    course of action would be to perform a rotational atherectomy on this very
    proximal circumflex which appeared angiographically to be heavily calcified.
    I felt this would give the best chance for getting stents to go further down
    the proximal and possibly into the mid left circumflex coronary artery. I
    felt we should try balloon angioplasty first and see how that went and then
    probably plan to switch to a rotoblater. I also felt that the patient had
    severe left ventricular systolic dysfunction and also had rather significant
    damping of pressure measured with the catheter tip with just diagnostic
    catheters for the cardiac catheterization. I therefore felt that we should
    use a side hole guide for the intervention and also should place intraaortic
    balloon pump. I also felt that we should place a venous sheath in case the
    patient needed to have a pacing catheter placed for the rotational
    atherectomy part of the procedure.

    We therefore turned our attention to the patient's left groin area. The left
    femoral area was anesthetized carefully. Using a Cook needle, the left
    femoral vein and left femoral artery were easily entered without any
    difficulty and a 6 French sheath was placed in the left femoral vein and a 6
    French sheath was placed in the left femoral artery. Both sheaths were
    aspirated and flushed. I then switched out for a 7.5 French balloon pump
    sheath in the patient's left femoral artery. We then advanced a 7.5 French
    intraaortic balloon catheter through the left femoral artery up into the
    patient's aorta without difficulty. The balloon pump catheter was carefully
    aspirated and flushed. It was connected up to the balloon pump console and
    excellent diastolic augmentation was obtained.

    The patient was then given 5000 units of intravenous heparin. We
    subsequently placed a 5 French pacing catheter out into the patient's right
    ventricle as well. Adequate pacing thresholds were obtained. The pacemaker
    was set in the VVI mode with backup ventricular pacing at a rate of
    approximately 50 beats per minute. It should be noted that during the
    rotational atherectomy, the patient did require transvenous pacing.

    I then placed a 6 French 4 left Judkins angioplasty guiding catheter with
    side holes up into the ostium of the patient's left main coronary artery.
    There was no damping of pressure measured at the catheter tip since there
    were side holes present. I then manipulated a 0.014 inch high-torque Floppy
    angioplasty wire down past the lesion out into the patient's proximal to mid
    left circumflex coronary artery. A couple of balloon inflations were made to
    6 atmospheres of pressure and subsequently to 4 and 5 atmospheres of
    pressure. There appeared to be significant waist present on the balloon. I
    felt that on the balloon would be insufficient. We therefore removed the
    balloon catheter. We switched out for a 2 mm Maverick angioplasty balloon
    catheter, the balloon being 9 mm in length. This balloon catheter was
    advanced down over the angioplasty wire out into the distal circumflex. We
    subsequently manipulated the angioplasty wire down out into the proximal
    aspect of the PDA. The balloon catheter was brought down into the PDA. We
    subsequently switched out for a 0.009 inch Floppy rotational atherectomy
    wire. This roto-wire was placed out into the posterior descending branch of
    the left circumflex coronary artery distally. I then removed the balloon
    catheter. We selected a 1.5 mm rotational atherectomy burr. This burr was
    brought down and tested outside the body at 164,000 RPMs. The rotational
    atherectomy burr was then brought down into position in the patient's left
    main coronary artery. Prior to every burr run, the patient received
    intracoronary injection of 200 micrograms of Verapamil. A total of 10 burr
    runs were then performed. We were able to successfully perform rotational
    atherectomy on the very proximal left circumflex coronary artery at its
    ostium extending into the proximal circumflex. The rotational atherectomy
    burr was removed. The guiding catheter, however, had softened somewhat. I
    felt that we needed to place a new guiding catheter. We removed the entire
    angioplasty system and switched out for a 6 French 3.5 Voda angioplasty
    guiding catheter with side holes. This guiding catheter was inserted into
    the ostium of the patient's left main coronary artery. I then manipulated a
    0.014 inch high-torque Floppy angioplasty wire down past the lesion out into
    the distal aspect of the patient's left circumflex coronary artery. When I
    was satisfied with the position of the angioplasty wire, we then were able to
    bring down a 2.5 mm Maverick angioplasty balloon catheter down into the mid
    left circumflex coronary artery. A balloon inflation was made to 9
    atmospheres of pressure and held for 24 seconds. I then removed the balloon
    catheter. I then selected a 2.75 mm Promus drug-eluding stent catheter with
    the stent being 15 mm in length. Prior to doing that, while the balloon
    catheter was still down, we switched out for a 0.014 inch Grand Slam
    angioplasty exchange wire. This wire is somewhat stiffer and I felt it would
    allow better support for placing stents. I then was able to surprisingly
    bring the Promus stent catheter down all the way through the proximal
    circumflex and all the way down out into the distal circumflex. I felt that
    we should stent the most distal lesion since we were able to bring a stent
    catheter down this far. The stent catheter was advanced out into the distal
    left circumflex coronary artery prior to its bifurcation. When I was
    satisfied with the position of the stent catheter, I inflated the stent
    catheter very carefully to 9 atmospheres of pressure and held this balloon
    inflation for 24 seconds. The stent catheter was then removed. I then
    selected another 2.75 mm Promus drug-eluding stent catheter, the stent being
    18 mm in length. This stent catheter was then brought down into position in
    such a way that it overlapped distally with the proximal aspect of the
    previously deployed stent. This stent catheter was placed in position and
    was then inflated for 11 atmospheres of pressure and was held for 45 seconds
    in order to deploy the stent. We then removed the stent catheter. I then
    selected another 2.75 mm Promus drug-eluding stent catheter with the catheter
    being 23 mm in length. This stent catheter was again placed in such a
    fashion that it overlapped the proximal aspect of the previously deployed
    stent. There were essentially overlapping stents from distal to proximal
    during this time. When I was satisfied with the position of this stent
    catheter, we inflated the catheter to 11 atmospheres of pressure and held
    this balloon inflation for 45 seconds as well.

    We then deflated the stent catheter and removed it. Serial cineangiograms
    really made the proximal and mid to distal left circumflex coronary artery to
    look quite good. I selected a 2.75 mm NC Voyager RX angioplasty balloon
    catheter. A total of three balloon inflations were made within the
    overlapping stented segment in the proximal to distal left circumflex
    coronary artery. The first balloon inflation distally was 18 atmospheres of
    pressure and the next subsequent two inflations were to 22 atmospheres of
    pressure. Each balloon inflation was held for approximately 35 seconds. We
    then deflated the NC Voyager high pressure angioplasty balloon catheter and
    removed it. I then selected a 3 mm Promus drug-eluding stent catheter, with
    the stent being 23 mm in length. This stent catheter was placed in such a
    way that the distal aspect of this new stent overlapped with the proximal
    aspect of the most recently deployed stent distally. The proximal aspect of
    this new stent was placed at the ostium of the left circumflex coronary
    artery at its takeoff. When I was satisfied with the position of the stent
    catheter, we inflated the stent catheter very carefully to 13 atmospheres of
    pressure and held this balloon inflation for 30 seconds. There was some
    waist noted in the very proximal aspect of the stent at the ostium at its
    takeoff from the left circumflex coronary artery from the left main coronary
    artery. We subsequently selected a 3 mm NC Merlin high pressure angioplasty
    balloon catheter, the balloon being 20 mm in length. Two balloon inflations
    were made within the stented segment proximally. Each balloon inflation was
    to 18 atmospheres of pressure and was held for 22 seconds. I then selected a
    3 mm Quantum Maverick high pressure angioplasty balloon catheter, the balloon
    being 12 mm in length. A high pressure balloon inflation was made in the
    very proximal aspect of the stented segment to 20 atmospheres of pressure and
    was held for 40 seconds. We then deflated the Quantum Maverick high pressure
    angioplasty balloon catheter and removed it. Subsequent cineangiograms
    revealed a very nice angiographic result. The stent was widely patent.
    There was excellent flow in the distal vessel. There was slight narrowing
    noted at the takeoff of the left circumflex coronary artery at its ostium.
    This was relatively mild in the 10 to 20% range. The entire overlapping
    stented segment, however, appeared widely patent and there was excellent flow
    in the distal circumflex. The angioplasty system was then removed. The
    pacemaker catheter was removed. The patient was taken upstairs in very
    stable condition. She was free of chest pain at the conclusion of the
    procedure and was hemodynamically stable. Her balloon pump was at 1 to 1
    during the case and was cut down to 1 to 2 when she left the cath lab. It
    will be pulled later on today.

    RESULTS

    ANGIOGRAPHY
    1. The left main coronary artery is normal.
    2. The left anterior descending coronary artery is totally occluded after
    the takeoff of the first septal and first diagonal branches. The
    first septal branch is fairly large in size and it has mild plaquing
    noted throughout. The first diagonal branch is moderate in size and
    has some mild disease present in its proximal aspect. This vessel,
    however, is too small for any type of catheter based intervention.
    3. The left circumflex coronary artery is a large and dominant vessel. In
    the very proximal circumflex, shortly after its takeoff at its ostium,
    there was a calcified complex 90% lesion noted. Further down in the
    proximal mid left circumflex coronary artery, there is a subsequent
    80% narrowing noted. In the mid left circumflex coronary artery more
    distally, there is a 60 to 70% lesion noted. At the distal circumflex
    prior to the takeoff of the distal obtuse marginal branches and
    posterior descending branch, there is a 60% lesion noted.
    4. The right coronary artery is a very small vessel which supplies very
    little myocardium.
    5. The saphenous vein bypass graft to the left anterior descending is
    patent with good runoff. The left anterior descending is a relatively
    small vessel distally, however.
    6. The saphenous vein bypass graft to the obtuse marginal branch of the
    left circumflex coronary artery is known to be totally occluded. It
    was not selectively injected.
    7. A left ventriculogram reveals severe global hypokinesis. The overall
    left ventricular ejection fraction was estimated to be approximately
    25%. The left ventricle appears mildly dilated. There is very
    minimal mitral regurgitation detected.
    8. After successful rotational atherectomy with subsequent implantation of
    four overlapping Promus drug-eluding stents into the very proximal
    left circumflex coronary artery at its ostium and extending down
    through the proximal circumflex out into the mid and subsequently the
    distal left circumflex coronary artery, the long area of severe
    disease with several 60 to 90% lesions preintervention was reduced to
    no residual narrowing postintervention. There was excellent flow in
    the distal vessel. There was no evidence of dissection.

    CONCLUSIONS
    1. Severely depressed global left ventricular systolic function as
    described above.
    2. Normal left main coronary artery.
    3. Totally occluded left anterior descending coronary artery after the
    first septal and first diagonal branch.
    4. Large and dominant left circumflex coronary artery which has a severe,
    high grade, complex, calcified lesion present in the very proximal
    aspect at its ostium at its takeoff from the left main coronary
    artery. There was also severe obstructive narrowing noted in the
    proximal mid and even distal left circumflex coronary artery prior to
    severe distal obtuse marginal branches as well as a posterior
    descending branch.
    5. Very small and nondominant right coronary artery which supplies very
    little myocardium.
    6. Widely patent saphenous vein bypass graft to the left anterior
    descending with the left anterior descending distally being a
    relatively small vessel.
    7. Successful rotational atherectomy of the very proximal left circumflex
    coronary artery with subsequent implantation of four overlapping
    Promus drug-eluding stents into the ostium of the left circumflex
    coronary artery extending throughout the proximal circumflex down into
    the mid and subsequently the distal left circumflex coronary artery.
    The proximal stent is a 3 mm Promus drug-eluding stent which is 23 mm
    in length. The three distal stents are all 2.75 mm Promus
    drug-eluding stents which are 23 mm, 18 mm, and 15 mm in length,
    respectively. The severely diseased and heavily calcified proximal
    left circumflex coronary artery with several severe lesions in the mid
    and distal left circumflex coronary artery preintervention was reduced
    to less than 10 to 20% residual narrowing in the very ostial part of
    the circumflex with no residual narrowing noted throughout the rest of
    the left circumflex coronary artery. There was no evidence of
    dissection and there was excellent flow in the distal vessel.
    8. Successful implantation of the intraaortic balloon pump via the right
    femoral artery for the interventional procedure.
    9. Successful insertion of a transvenous temporary ventricular pacemaker
    from the left femoral vein.
    Last edited by jlb102780; 10-30-2009 at 05:03 AM.
    Jammie Barsamian, CPC, CCC, CEMC, CCS-P, CPMA

  2. #2
    Default
    This is the very reason I don't want to do cardiology!!! You are the bomb! I wish I could be of any sort of help, you I'm frazzled!!!

  3. #3
    Location
    Birmingham, Alabama
    Posts
    890
    Default
    Quote Originally Posted by jlb102780 View Post
    Here's what I got from the report (which is very long, so thank you to everyone that reads it )any suggestions or additional comments would be wonderful

    92980-LD
    33970
    33971
    33210
    71090-26
    93510-26
    93545
    93556-2659
    93543
    93555-2659
    93540

    NAME OF TEST:
    1. Left heart cardiac catheterization.
    2. Coronary angiography.
    3. Left ventriculography.
    4. Saphenous vein bypass graft injection.
    5. Rotational atherectomy with subsequent implantation of four overlapping
    Promus drug-eluding intracoronary stents into the very proximal aspect
    of the left circumflex coronary artery, including its ostium all the
    way down into the distal left circumflex coronary artery.
    6. Insertion of an intraaortic balloon pump via the left femoral artery.
    7. Insertion of a transvenous temporary pacemaker via the left femoral
    vein.

    HISTORY
    The patient is a very pleasant, 62-year-old female with a history of known
    atherosclerotic coronary artery disease. She actually underwent coronary
    artery bypass surgery back several years ago. She had two bypass grafts
    placed at that time. She had a single bypass graft off her aorta which
    bifurcated and one limb went to her left anterior descending and second limb
    went to the obtuse marginal branch of the left circumflex coronary artery.
    At the time of her previous cardiac catheterization two years ago, she was
    noted to have the limb to the obtuse marginal branch to be totally occluded.
    The graft to the left anterior descending was patent. She has a nondominant
    right coronary artery. The patient presented to Baptist Medical Center with
    some GI type symptoms. She subsequently developed an episode of severe chest
    pain after being in the hospital and was noted to have transient ST segment
    elevation in leads 1 and AVL along with marked reciprocal ST segment
    depression in her anterior precordial leads as well as in her inferior leads.
    After stabilization, she was brought to the cardiac catheterization
    laboratory for further evaluation today.

    PROCEDURE
    The patient was brought to the cardiac catheterization laboratory in very
    stable condition. The right groin area was prepped and draped in the usual
    sterile fashion. Using 1% Xylocaine, the right femoral area was
    anesthetized. Using a Cook needle, the right femoral artery was easily
    entered without any difficulty and a 6 French sheath was placed via the
    Seldinger technique. This sheath was aspirated and flushed. Diagnostic
    coronary angiography was then performed utilizing a 6 French 4 left Judkins 5
    French 4 left Judkins catheters in order to inject the patient's left
    coronary artery. It should be noted that the patient had marked dampening
    of pressure when both catheters were inserted. The right coronary artery was
    injected non-selectively with a 4 French 4 Williams right coronary diagnostic
    catheter. The patient was noted to have a small, nondominant right coronary
    artery which supplies very little myocardium from a previous cardiac
    catheterization. Utilizing the same 5 French Williams right coronary
    diagnostic catheter, we were able to manipulate the catheter into the bypass
    graft to the left anterior descending. This saphenous vein bypass graft to
    the left anterior descending was injected.

    We then performed a left ventriculogram in the 30 degree RAO projection
    utilizing a 6 French angled pigtail catheter. This angled pigtail catheter
    was then pulled back across the aortic valve in order to measure any possible
    transaortic valve gradient. Upon reviewing the patient's cineangiograms, it
    was very obvious that the patient had rather pronounced left ventricular
    systolic dysfunction. Her left ventricle appeared to have an ejection
    fraction of approximately 25%. This was clearly worse than it had been on
    previous cardiac catheterization a couple of years ago. She had a patent
    bypass graft to the left anterior descending. Her right coronary artery, as
    mentioned earlier, was a small vessel which was nondominant. The patient had
    severe disease in her proximal left circumflex coronary artery with an 80%
    calcified lesion in the ostial part of the circumflex at its takeoff from the
    left main. In the proximal circumflex, further downstream, there was a 70%
    narrowing noted. In the mid left circumflex coronary artery, there was a 60%
    narrowing noted. In the distal left circumflex coronary artery prior to a
    couple of distal obtuse marginal branches and a posterior descending branch,
    there is a 60% lesion noted.

    After careful review of the patient's cineangiograms, I felt that the best
    course of action would be to perform a rotational atherectomy on this very
    proximal circumflex which appeared angiographically to be heavily calcified.
    I felt this would give the best chance for getting stents to go further down
    the proximal and possibly into the mid left circumflex coronary artery. I
    felt we should try balloon angioplasty first and see how that went and then
    probably plan to switch to a rotoblater. I also felt that the patient had
    severe left ventricular systolic dysfunction and also had rather significant
    damping of pressure measured with the catheter tip with just diagnostic
    catheters for the cardiac catheterization. I therefore felt that we should
    use a side hole guide for the intervention and also should place intraaortic
    balloon pump. I also felt that we should place a venous sheath in case the
    patient needed to have a pacing catheter placed for the rotational
    atherectomy part of the procedure.

    We therefore turned our attention to the patient's left groin area. The left
    femoral area was anesthetized carefully. Using a Cook needle, the left
    femoral vein and left femoral artery were easily entered without any
    difficulty and a 6 French sheath was placed in the left femoral vein and a 6
    French sheath was placed in the left femoral artery. Both sheaths were
    aspirated and flushed. I then switched out for a 7.5 French balloon pump
    sheath in the patient's left femoral artery. We then advanced a 7.5 French
    intraaortic balloon catheter through the left femoral artery up into the
    patient's aorta without difficulty. The balloon pump catheter was carefully
    aspirated and flushed. It was connected up to the balloon pump console and
    excellent diastolic augmentation was obtained.

    The patient was then given 5000 units of intravenous heparin. We
    subsequently placed a 5 French pacing catheter out into the patient's right
    ventricle as well. Adequate pacing thresholds were obtained. The pacemaker
    was set in the VVI mode with backup ventricular pacing at a rate of
    approximately 50 beats per minute. It should be noted that during the
    rotational atherectomy, the patient did require transvenous pacing.

    I then placed a 6 French 4 left Judkins angioplasty guiding catheter with
    side holes up into the ostium of the patient's left main coronary artery.
    There was no damping of pressure measured at the catheter tip since there
    were side holes present. I then manipulated a 0.014 inch high-torque Floppy
    angioplasty wire down past the lesion out into the patient's proximal to mid
    left circumflex coronary artery. A couple of balloon inflations were made to
    6 atmospheres of pressure and subsequently to 4 and 5 atmospheres of
    pressure. There appeared to be significant waist present on the balloon. I
    felt that on the balloon would be insufficient. We therefore removed the
    balloon catheter. We switched out for a 2 mm Maverick angioplasty balloon
    catheter, the balloon being 9 mm in length. This balloon catheter was
    advanced down over the angioplasty wire out into the distal circumflex. We
    subsequently manipulated the angioplasty wire down out into the proximal
    aspect of the PDA. The balloon catheter was brought down into the PDA. We
    subsequently switched out for a 0.009 inch Floppy rotational atherectomy
    wire. This roto-wire was placed out into the posterior descending branch of
    the left circumflex coronary artery distally. I then removed the balloon
    catheter. We selected a 1.5 mm rotational atherectomy burr. This burr was
    brought down and tested outside the body at 164,000 RPMs. The rotational
    atherectomy burr was then brought down into position in the patient's left
    main coronary artery. Prior to every burr run, the patient received
    intracoronary injection of 200 micrograms of Verapamil. A total of 10 burr
    runs were then performed. We were able to successfully perform rotational
    atherectomy on the very proximal left circumflex coronary artery at its
    ostium extending into the proximal circumflex. The rotational atherectomy
    burr was removed. The guiding catheter, however, had softened somewhat. I
    felt that we needed to place a new guiding catheter. We removed the entire
    angioplasty system and switched out for a 6 French 3.5 Voda angioplasty
    guiding catheter with side holes. This guiding catheter was inserted into
    the ostium of the patient's left main coronary artery. I then manipulated a
    0.014 inch high-torque Floppy angioplasty wire down past the lesion out into
    the distal aspect of the patient's left circumflex coronary artery. When I
    was satisfied with the position of the angioplasty wire, we then were able to
    bring down a 2.5 mm Maverick angioplasty balloon catheter down into the mid
    left circumflex coronary artery. A balloon inflation was made to 9
    atmospheres of pressure and held for 24 seconds. I then removed the balloon
    catheter. I then selected a 2.75 mm Promus drug-eluding stent catheter with
    the stent being 15 mm in length. Prior to doing that, while the balloon
    catheter was still down, we switched out for a 0.014 inch Grand Slam
    angioplasty exchange wire. This wire is somewhat stiffer and I felt it would
    allow better support for placing stents. I then was able to surprisingly
    bring the Promus stent catheter down all the way through the proximal
    circumflex and all the way down out into the distal circumflex. I felt that
    we should stent the most distal lesion since we were able to bring a stent
    catheter down this far. The stent catheter was advanced out into the distal
    left circumflex coronary artery prior to its bifurcation. When I was
    satisfied with the position of the stent catheter, I inflated the stent
    catheter very carefully to 9 atmospheres of pressure and held this balloon
    inflation for 24 seconds. The stent catheter was then removed. I then
    selected another 2.75 mm Promus drug-eluding stent catheter, the stent being
    18 mm in length. This stent catheter was then brought down into position in
    such a way that it overlapped distally with the proximal aspect of the
    previously deployed stent. This stent catheter was placed in position and
    was then inflated for 11 atmospheres of pressure and was held for 45 seconds
    in order to deploy the stent. We then removed the stent catheter. I then
    selected another 2.75 mm Promus drug-eluding stent catheter with the catheter
    being 23 mm in length. This stent catheter was again placed in such a
    fashion that it overlapped the proximal aspect of the previously deployed
    stent. There were essentially overlapping stents from distal to proximal
    during this time. When I was satisfied with the position of this stent
    catheter, we inflated the catheter to 11 atmospheres of pressure and held
    this balloon inflation for 45 seconds as well.

    We then deflated the stent catheter and removed it. Serial cineangiograms
    really made the proximal and mid to distal left circumflex coronary artery to
    look quite good. I selected a 2.75 mm NC Voyager RX angioplasty balloon
    catheter. A total of three balloon inflations were made within the
    overlapping stented segment in the proximal to distal left circumflex
    coronary artery. The first balloon inflation distally was 18 atmospheres of
    pressure and the next subsequent two inflations were to 22 atmospheres of
    pressure. Each balloon inflation was held for approximately 35 seconds. We
    then deflated the NC Voyager high pressure angioplasty balloon catheter and
    removed it. I then selected a 3 mm Promus drug-eluding stent catheter, with
    the stent being 23 mm in length. This stent catheter was placed in such a
    way that the distal aspect of this new stent overlapped with the proximal
    aspect of the most recently deployed stent distally. The proximal aspect of
    this new stent was placed at the ostium of the left circumflex coronary
    artery at its takeoff. When I was satisfied with the position of the stent
    catheter, we inflated the stent catheter very carefully to 13 atmospheres of
    pressure and held this balloon inflation for 30 seconds. There was some
    waist noted in the very proximal aspect of the stent at the ostium at its
    takeoff from the left circumflex coronary artery from the left main coronary
    artery. We subsequently selected a 3 mm NC Merlin high pressure angioplasty
    balloon catheter, the balloon being 20 mm in length. Two balloon inflations
    were made within the stented segment proximally. Each balloon inflation was
    to 18 atmospheres of pressure and was held for 22 seconds. I then selected a
    3 mm Quantum Maverick high pressure angioplasty balloon catheter, the balloon
    being 12 mm in length. A high pressure balloon inflation was made in the
    very proximal aspect of the stented segment to 20 atmospheres of pressure and
    was held for 40 seconds. We then deflated the Quantum Maverick high pressure
    angioplasty balloon catheter and removed it. Subsequent cineangiograms
    revealed a very nice angiographic result. The stent was widely patent.
    There was excellent flow in the distal vessel. There was slight narrowing
    noted at the takeoff of the left circumflex coronary artery at its ostium.
    This was relatively mild in the 10 to 20% range. The entire overlapping
    stented segment, however, appeared widely patent and there was excellent flow
    in the distal circumflex. The angioplasty system was then removed. The
    pacemaker catheter was removed. The patient was taken upstairs in very
    stable condition. She was free of chest pain at the conclusion of the
    procedure and was hemodynamically stable. Her balloon pump was at 1 to 1
    during the case and was cut down to 1 to 2 when she left the cath lab. It
    will be pulled later on today.

    RESULTS

    ANGIOGRAPHY
    1. The left main coronary artery is normal.
    2. The left anterior descending coronary artery is totally occluded after
    the takeoff of the first septal and first diagonal branches. The
    first septal branch is fairly large in size and it has mild plaquing
    noted throughout. The first diagonal branch is moderate in size and
    has some mild disease present in its proximal aspect. This vessel,
    however, is too small for any type of catheter based intervention.
    3. The left circumflex coronary artery is a large and dominant vessel. In
    the very proximal circumflex, shortly after its takeoff at its ostium,
    there was a calcified complex 90% lesion noted. Further down in the
    proximal mid left circumflex coronary artery, there is a subsequent
    80% narrowing noted. In the mid left circumflex coronary artery more
    distally, there is a 60 to 70% lesion noted. At the distal circumflex
    prior to the takeoff of the distal obtuse marginal branches and
    posterior descending branch, there is a 60% lesion noted.
    4. The right coronary artery is a very small vessel which supplies very
    little myocardium.
    5. The saphenous vein bypass graft to the left anterior descending is
    patent with good runoff. The left anterior descending is a relatively
    small vessel distally, however.
    6. The saphenous vein bypass graft to the obtuse marginal branch of the
    left circumflex coronary artery is known to be totally occluded. It
    was not selectively injected.
    7. A left ventriculogram reveals severe global hypokinesis. The overall
    left ventricular ejection fraction was estimated to be approximately
    25%. The left ventricle appears mildly dilated. There is very
    minimal mitral regurgitation detected.
    8. After successful rotational atherectomy with subsequent implantation of
    four overlapping Promus drug-eluding stents into the very proximal
    left circumflex coronary artery at its ostium and extending down
    through the proximal circumflex out into the mid and subsequently the
    distal left circumflex coronary artery, the long area of severe
    disease with several 60 to 90% lesions preintervention was reduced to
    no residual narrowing postintervention. There was excellent flow in
    the distal vessel. There was no evidence of dissection.

    CONCLUSIONS
    1. Severely depressed global left ventricular systolic function as
    described above.
    2. Normal left main coronary artery.
    3. Totally occluded left anterior descending coronary artery after the
    first septal and first diagonal branch.
    4. Large and dominant left circumflex coronary artery which has a severe,
    high grade, complex, calcified lesion present in the very proximal
    aspect at its ostium at its takeoff from the left main coronary
    artery. There was also severe obstructive narrowing noted in the
    proximal mid and even distal left circumflex coronary artery prior to
    severe distal obtuse marginal branches as well as a posterior
    descending branch.
    5. Very small and nondominant right coronary artery which supplies very
    little myocardium.
    6. Widely patent saphenous vein bypass graft to the left anterior
    descending with the left anterior descending distally being a
    relatively small vessel.
    7. Successful rotational atherectomy of the very proximal left circumflex
    coronary artery with subsequent implantation of four overlapping
    Promus drug-eluding stents into the ostium of the left circumflex
    coronary artery extending throughout the proximal circumflex down into
    the mid and subsequently the distal left circumflex coronary artery.
    The proximal stent is a 3 mm Promus drug-eluding stent which is 23 mm
    in length. The three distal stents are all 2.75 mm Promus
    drug-eluding stents which are 23 mm, 18 mm, and 15 mm in length,
    respectively. The severely diseased and heavily calcified proximal
    left circumflex coronary artery with several severe lesions in the mid
    and distal left circumflex coronary artery preintervention was reduced
    to less than 10 to 20% residual narrowing in the very ostial part of
    the circumflex with no residual narrowing noted throughout the rest of
    the left circumflex coronary artery. There was no evidence of
    dissection and there was excellent flow in the distal vessel.
    8. Successful implantation of the intraaortic balloon pump via the right
    femoral artery for the interventional procedure.
    9. Successful insertion of a transvenous temporary ventricular pacemaker
    from the left femoral vein.
    wow, that is a long report...here goes:
    92980 LC for the stents
    93510 for the LHC
    33967 IABP
    33210-59 Temp Pacer
    93540 Injection of Venous Graft
    93545 Injection of Coronary arteries
    93543 Injection of LT Ventrical
    93555 26,59 Supervision/Interpretation of Lt Ventriculography
    93556 26,59 S & I of Coronary Arteries

    I would not charge for the removal of the IABP or Temp Pacer, nor the Atherectomy and Angioplasty of the LC (included with stent placement).
    I think that is everything...
    HTH
    Last edited by dpeoples; 10-29-2009 at 02:54 PM. Reason: modifiers
    Danny L. Peoples
    CIRCC,CPC

  4. #4
    Default
    Quote Originally Posted by jlb102780 View Post
    Here's what I got from the report (which is very long, so thank you to everyone that reads it )any suggestions or additional comments would be wonderful

    92980-LC
    33970
    33971
    33210
    71090-26
    93510-26
    93545
    93556-2659
    93543
    93555-2659
    93540


    NAME OF TEST:
    1. Left heart cardiac catheterization.
    2. Coronary angiography.
    3. Left ventriculography.
    4. Saphenous vein bypass graft injection.
    5. Rotational atherectomy with subsequent implantation of four overlapping
    Promus drug-eluding intracoronary stents into the very proximal aspect
    of the left circumflex coronary artery, including its ostium all the
    way down into the distal left circumflex coronary artery.
    6. Insertion of an intraaortic balloon pump via the left femoral artery.
    7. Insertion of a transvenous temporary pacemaker via the left femoral
    vein.

    HISTORY
    The patient is a very pleasant, 62-year-old female with a history of known
    atherosclerotic coronary artery disease. She actually underwent coronary
    artery bypass surgery back several years ago. She had two bypass grafts
    placed at that time. She had a single bypass graft off her aorta which
    bifurcated and one limb went to her left anterior descending and second limb
    went to the obtuse marginal branch of the left circumflex coronary artery.
    At the time of her previous cardiac catheterization two years ago, she was
    noted to have the limb to the obtuse marginal branch to be totally occluded.
    The graft to the left anterior descending was patent. She has a nondominant
    right coronary artery. The patient presented to Baptist Medical Center with
    some GI type symptoms. She subsequently developed an episode of severe chest
    pain after being in the hospital and was noted to have transient ST segment
    elevation in leads 1 and AVL along with marked reciprocal ST segment
    depression in her anterior precordial leads as well as in her inferior leads.
    After stabilization, she was brought to the cardiac catheterization
    laboratory for further evaluation today.

    PROCEDURE
    The patient was brought to the cardiac catheterization laboratory in very
    stable condition. The right groin area was prepped and draped in the usual
    sterile fashion. Using 1% Xylocaine, the right femoral area was
    anesthetized. Using a Cook needle, the right femoral artery was easily
    entered without any difficulty and a 6 French sheath was placed via the
    Seldinger technique. This sheath was aspirated and flushed. Diagnostic
    coronary angiography was then performed utilizing a 6 French 4 left Judkins 5
    French 4 left Judkins catheters in order to inject the patient's left
    coronary artery. It should be noted that the patient had marked dampening
    of pressure when both catheters were inserted. The right coronary artery was
    injected non-selectively with a 4 French 4 Williams right coronary diagnostic
    catheter. The patient was noted to have a small, nondominant right coronary
    artery which supplies very little myocardium from a previous cardiac
    catheterization. Utilizing the same 5 French Williams right coronary
    diagnostic catheter, we were able to manipulate the catheter into the bypass
    graft to the left anterior descending. This saphenous vein bypass graft to
    the left anterior descending was injected.

    We then performed a left ventriculogram in the 30 degree RAO projection
    utilizing a 6 French angled pigtail catheter. This angled pigtail catheter
    was then pulled back across the aortic valve in order to measure any possible
    transaortic valve gradient. Upon reviewing the patient's cineangiograms, it
    was very obvious that the patient had rather pronounced left ventricular
    systolic dysfunction. Her left ventricle appeared to have an ejection
    fraction of approximately 25%. This was clearly worse than it had been on
    previous cardiac catheterization a couple of years ago. She had a patent
    bypass graft to the left anterior descending. Her right coronary artery, as
    mentioned earlier, was a small vessel which was nondominant. The patient had
    severe disease in her proximal left circumflex coronary artery with an 80%
    calcified lesion in the ostial part of the circumflex at its takeoff from the
    left main. In the proximal circumflex, further downstream, there was a 70%
    narrowing noted. In the mid left circumflex coronary artery, there was a 60%
    narrowing noted. In the distal left circumflex coronary artery prior to a
    couple of distal obtuse marginal branches and a posterior descending branch,
    there is a 60% lesion noted.

    After careful review of the patient's cineangiograms, I felt that the best
    course of action would be to perform a rotational atherectomy on this very
    proximal circumflex which appeared angiographically to be heavily calcified.
    I felt this would give the best chance for getting stents to go further down
    the proximal and possibly into the mid left circumflex coronary artery. I
    felt we should try balloon angioplasty first and see how that went and then
    probably plan to switch to a rotoblater. I also felt that the patient had
    severe left ventricular systolic dysfunction and also had rather significant
    damping of pressure measured with the catheter tip with just diagnostic
    catheters for the cardiac catheterization. I therefore felt that we should
    use a side hole guide for the intervention and also should place intraaortic
    balloon pump. I also felt that we should place a venous sheath in case the
    patient needed to have a pacing catheter placed for the rotational
    atherectomy part of the procedure.

    We therefore turned our attention to the patient's left groin area. The left
    femoral area was anesthetized carefully. Using a Cook needle, the left
    femoral vein and left femoral artery were easily entered without any
    difficulty and a 6 French sheath was placed in the left femoral vein and a 6
    French sheath was placed in the left femoral artery. Both sheaths were
    aspirated and flushed. I then switched out for a 7.5 French balloon pump
    sheath in the patient's left femoral artery. We then advanced a 7.5 French
    intraaortic balloon catheter through the left femoral artery up into the
    patient's aorta without difficulty. The balloon pump catheter was carefully
    aspirated and flushed. It was connected up to the balloon pump console and
    excellent diastolic augmentation was obtained.

    The patient was then given 5000 units of intravenous heparin. We
    subsequently placed a 5 French pacing catheter out into the patient's right
    ventricle as well. Adequate pacing thresholds were obtained. The pacemaker
    was set in the VVI mode with backup ventricular pacing at a rate of
    approximately 50 beats per minute. It should be noted that during the
    rotational atherectomy, the patient did require transvenous pacing.

    I then placed a 6 French 4 left Judkins angioplasty guiding catheter with
    side holes up into the ostium of the patient's left main coronary artery.
    There was no damping of pressure measured at the catheter tip since there
    were side holes present. I then manipulated a 0.014 inch high-torque Floppy
    angioplasty wire down past the lesion out into the patient's proximal to mid
    left circumflex coronary artery. A couple of balloon inflations were made to
    6 atmospheres of pressure and subsequently to 4 and 5 atmospheres of
    pressure. There appeared to be significant waist present on the balloon. I
    felt that on the balloon would be insufficient. We therefore removed the
    balloon catheter. We switched out for a 2 mm Maverick angioplasty balloon
    catheter, the balloon being 9 mm in length. This balloon catheter was
    advanced down over the angioplasty wire out into the distal circumflex. We
    subsequently manipulated the angioplasty wire down out into the proximal
    aspect of the PDA. The balloon catheter was brought down into the PDA. We
    subsequently switched out for a 0.009 inch Floppy rotational atherectomy
    wire. This roto-wire was placed out into the posterior descending branch of
    the left circumflex coronary artery distally. I then removed the balloon
    catheter. We selected a 1.5 mm rotational atherectomy burr. This burr was
    brought down and tested outside the body at 164,000 RPMs. The rotational
    atherectomy burr was then brought down into position in the patient's left
    main coronary artery. Prior to every burr run, the patient received
    intracoronary injection of 200 micrograms of Verapamil. A total of 10 burr
    runs were then performed. We were able to successfully perform rotational
    atherectomy on the very proximal left circumflex coronary artery at its
    ostium extending into the proximal circumflex. The rotational atherectomy
    burr was removed. The guiding catheter, however, had softened somewhat. I
    felt that we needed to place a new guiding catheter. We removed the entire
    angioplasty system and switched out for a 6 French 3.5 Voda angioplasty
    guiding catheter with side holes. This guiding catheter was inserted into
    the ostium of the patient's left main coronary artery. I then manipulated a
    0.014 inch high-torque Floppy angioplasty wire down past the lesion out into
    the distal aspect of the patient's left circumflex coronary artery. When I
    was satisfied with the position of the angioplasty wire, we then were able to
    bring down a 2.5 mm Maverick angioplasty balloon catheter down into the mid
    left circumflex coronary artery. A balloon inflation was made to 9
    atmospheres of pressure and held for 24 seconds. I then removed the balloon
    catheter. I then selected a 2.75 mm Promus drug-eluding stent catheter with
    the stent being 15 mm in length. Prior to doing that, while the balloon
    catheter was still down, we switched out for a 0.014 inch Grand Slam
    angioplasty exchange wire. This wire is somewhat stiffer and I felt it would
    allow better support for placing stents. I then was able to surprisingly
    bring the Promus stent catheter down all the way through the proximal
    circumflex and all the way down out into the distal circumflex. I felt that
    we should stent the most distal lesion since we were able to bring a stent
    catheter down this far. The stent catheter was advanced out into the distal
    left circumflex coronary artery prior to its bifurcation. When I was
    satisfied with the position of the stent catheter, I inflated the stent
    catheter very carefully to 9 atmospheres of pressure and held this balloon
    inflation for 24 seconds. The stent catheter was then removed. I then
    selected another 2.75 mm Promus drug-eluding stent catheter, the stent being
    18 mm in length. This stent catheter was then brought down into position in
    such a way that it overlapped distally with the proximal aspect of the
    previously deployed stent. This stent catheter was placed in position and
    was then inflated for 11 atmospheres of pressure and was held for 45 seconds
    in order to deploy the stent. We then removed the stent catheter. I then
    selected another 2.75 mm Promus drug-eluding stent catheter with the catheter
    being 23 mm in length. This stent catheter was again placed in such a
    fashion that it overlapped the proximal aspect of the previously deployed
    stent. There were essentially overlapping stents from distal to proximal
    during this time. When I was satisfied with the position of this stent
    catheter, we inflated the catheter to 11 atmospheres of pressure and held
    this balloon inflation for 45 seconds as well.

    We then deflated the stent catheter and removed it. Serial cineangiograms
    really made the proximal and mid to distal left circumflex coronary artery to
    look quite good. I selected a 2.75 mm NC Voyager RX angioplasty balloon
    catheter. A total of three balloon inflations were made within the
    overlapping stented segment in the proximal to distal left circumflex
    coronary artery. The first balloon inflation distally was 18 atmospheres of
    pressure and the next subsequent two inflations were to 22 atmospheres of
    pressure. Each balloon inflation was held for approximately 35 seconds. We
    then deflated the NC Voyager high pressure angioplasty balloon catheter and
    removed it. I then selected a 3 mm Promus drug-eluding stent catheter, with
    the stent being 23 mm in length. This stent catheter was placed in such a
    way that the distal aspect of this new stent overlapped with the proximal
    aspect of the most recently deployed stent distally. The proximal aspect of
    this new stent was placed at the ostium of the left circumflex coronary
    artery at its takeoff. When I was satisfied with the position of the stent
    catheter, we inflated the stent catheter very carefully to 13 atmospheres of
    pressure and held this balloon inflation for 30 seconds. There was some
    waist noted in the very proximal aspect of the stent at the ostium at its
    takeoff from the left circumflex coronary artery from the left main coronary
    artery. We subsequently selected a 3 mm NC Merlin high pressure angioplasty
    balloon catheter, the balloon being 20 mm in length. Two balloon inflations
    were made within the stented segment proximally. Each balloon inflation was
    to 18 atmospheres of pressure and was held for 22 seconds. I then selected a
    3 mm Quantum Maverick high pressure angioplasty balloon catheter, the balloon
    being 12 mm in length. A high pressure balloon inflation was made in the
    very proximal aspect of the stented segment to 20 atmospheres of pressure and
    was held for 40 seconds. We then deflated the Quantum Maverick high pressure
    angioplasty balloon catheter and removed it. Subsequent cineangiograms
    revealed a very nice angiographic result. The stent was widely patent.
    There was excellent flow in the distal vessel. There was slight narrowing
    noted at the takeoff of the left circumflex coronary artery at its ostium.
    This was relatively mild in the 10 to 20% range. The entire overlapping
    stented segment, however, appeared widely patent and there was excellent flow
    in the distal circumflex. The angioplasty system was then removed. The
    pacemaker catheter was removed. The patient was taken upstairs in very
    stable condition. She was free of chest pain at the conclusion of the
    procedure and was hemodynamically stable. Her balloon pump was at 1 to 1
    during the case and was cut down to 1 to 2 when she left the cath lab. It
    will be pulled later on today.

    RESULTS

    ANGIOGRAPHY
    1. The left main coronary artery is normal.
    2. The left anterior descending coronary artery is totally occluded after
    the takeoff of the first septal and first diagonal branches. The
    first septal branch is fairly large in size and it has mild plaquing
    noted throughout. The first diagonal branch is moderate in size and
    has some mild disease present in its proximal aspect. This vessel,
    however, is too small for any type of catheter based intervention.
    3. The left circumflex coronary artery is a large and dominant vessel. In
    the very proximal circumflex, shortly after its takeoff at its ostium,
    there was a calcified complex 90% lesion noted. Further down in the
    proximal mid left circumflex coronary artery, there is a subsequent
    80% narrowing noted. In the mid left circumflex coronary artery more
    distally, there is a 60 to 70% lesion noted. At the distal circumflex
    prior to the takeoff of the distal obtuse marginal branches and
    posterior descending branch, there is a 60% lesion noted.
    4. The right coronary artery is a very small vessel which supplies very
    little myocardium.
    5. The saphenous vein bypass graft to the left anterior descending is
    patent with good runoff. The left anterior descending is a relatively
    small vessel distally, however.
    6. The saphenous vein bypass graft to the obtuse marginal branch of the
    left circumflex coronary artery is known to be totally occluded. It
    was not selectively injected.
    7. A left ventriculogram reveals severe global hypokinesis. The overall
    left ventricular ejection fraction was estimated to be approximately
    25%. The left ventricle appears mildly dilated. There is very
    minimal mitral regurgitation detected.
    8. After successful rotational atherectomy with subsequent implantation of
    four overlapping Promus drug-eluding stents into the very proximal
    left circumflex coronary artery at its ostium and extending down
    through the proximal circumflex out into the mid and subsequently the
    distal left circumflex coronary artery, the long area of severe
    disease with several 60 to 90% lesions preintervention was reduced to
    no residual narrowing postintervention. There was excellent flow in
    the distal vessel. There was no evidence of dissection.

    CONCLUSIONS
    1. Severely depressed global left ventricular systolic function as
    described above.
    2. Normal left main coronary artery.
    3. Totally occluded left anterior descending coronary artery after the
    first septal and first diagonal branch.
    4. Large and dominant left circumflex coronary artery which has a severe,
    high grade, complex, calcified lesion present in the very proximal
    aspect at its ostium at its takeoff from the left main coronary
    artery. There was also severe obstructive narrowing noted in the
    proximal mid and even distal left circumflex coronary artery prior to
    severe distal obtuse marginal branches as well as a posterior
    descending branch.
    5. Very small and nondominant right coronary artery which supplies very
    little myocardium.
    6. Widely patent saphenous vein bypass graft to the left anterior
    descending with the left anterior descending distally being a
    relatively small vessel.
    7. Successful rotational atherectomy of the very proximal left circumflex
    coronary artery with subsequent implantation of four overlapping
    Promus drug-eluding stents into the ostium of the left circumflex
    coronary artery extending throughout the proximal circumflex down into
    the mid and subsequently the distal left circumflex coronary artery.
    The proximal stent is a 3 mm Promus drug-eluding stent which is 23 mm
    in length. The three distal stents are all 2.75 mm Promus
    drug-eluding stents which are 23 mm, 18 mm, and 15 mm in length,
    respectively. The severely diseased and heavily calcified proximal
    left circumflex coronary artery with several severe lesions in the mid
    and distal left circumflex coronary artery preintervention was reduced
    to less than 10 to 20% residual narrowing in the very ostial part of
    the circumflex with no residual narrowing noted throughout the rest of
    the left circumflex coronary artery. There was no evidence of
    dissection and there was excellent flow in the distal vessel.
    8. Successful implantation of the intraaortic balloon pump via the right
    femoral artery for the interventional procedure.
    9. Successful insertion of a transvenous temporary ventricular pacemaker
    from the left femoral vein.
    The way you coded seems to be perfect except that I don't see a code for implantation of the intraaortic ballon pump . Is it inclusive of the angio stent code. I am not sure. Please check on that one. I don't have any of my literature handy now to check on it. In case if you get to know about it let me know. Otherwise everything is good. Also I only wish I get such a descriptive op reports for me to code . Good luck.
    skk

  5. Smile
    dpeoples has coded this report correctly, I was in cardiology but am now in pathology but that is not that uncommon of a report and the coding dpeoples gave was exactly what I would use. No codes for removals.

    lisa

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