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Need help coding

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    Medical Coding Books


    IMPRESSION: There is no significant focal stenosis nor obstruction of coronary arteries.

    PATIENT'S RISK FACTORS: Increased cholesterol with 30 years of smoking history.

    INDICATIONS: Coronary artery disease is suspected.

    CONSENT: Written informed consent was obtained prior to the examination from the patient after risks and benefits of the procedure were explained.

    TECHNIQUE: This imaging study was accomplished using a 64 slice Toshiba Aquilion MD CT scanner using EKG gated prospective triggering. Volumetric acquisition was made from the level of the carina to the base of the left ventricle. Volumetric reconstructed and curved planar reformatted images were reconstructed. Vessel analysis were performed at the Vitrea workstation. 5.0 ml of Metoprolol was given intravenously right before the examination. One tablet of Nitroglycerin was given sublingually just before the contrast administration. Total 80 cc of Isovue 370 non-ionic intravenous contrast was given at 5 cc per second with 18 gauge Angiocath needle. Bolus chase of 40 cc of saline was given at 5.0 cc per second.


    Coronary CT Angiography: The anatomy of the coronary arteries are normal. Right sided dominance is demonstrated.

    Left Main: There is no evidence of calcified or non-calcified coronary plaque formation.

    Left Anterior Descending: There are two small calcified coronary plaque formations. There is no focal area of significant stenosis nor obstruction.

    Left Circumflex: There is no calcified or non-calcified coronary plaque formation.

    Right Coronary Artery: Calcified plaque formation is demonstrated at the distal portion of proximal coronary artery. There is no significant focal area of stenosis nor obstruction.

    Other Findings: No abnormal filling defects are demonstrated in the pulmonary vasculature. Visualized lung fields demonstrate no suspicious nodule nor infiltrates. Visualized thoracic aorta is normal in caliber and contour.

  2. Default
    Can I bill for EKG, Isovue, Metoprolol, Nitrostat? Thanks in advance for the help :-)

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