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Please help guide with coding this cath report

  1. Question Please help guide with coding this cath report
    Medical Coding Books
    Please help guide with coding this cath report. I can use your help, thanks.

    Vessel Angiograply Findings
    The coronary tree has a right dominance.
    LM: Moderated ectasia of the Left Mail.
    LAD: Moderated ectasia of the proximal LAD. There is a 40%-50% stenosis in the mid LAD.
    Mild diffuse disease in the distal LAD
    Ramus I: Moderated diffuse disease in the ramus intermedius. Mild ectasia of the ramus intermedius.
    LCX: Mild diffuse disease in the mid circumflex.
    RCA:Mild extasia of the proximal RCA. There is a 40% stenosis in the proximal RCA. At the bend of the proximal RCA. Moderated extasia of the mid RCA. Severe ectasia of the distal RCA. Mild diffuse disease in the PDA of the RCA.

    Left Ventriculography
    EF: 45% EF Method: EF estimated

    Left Ventriculography Findings
    Normal left ventricular function (hand injection)

    Other Angiographic Findings
    Peripheral Angiograply:
    Tortuous iliac arteries with no significant disease.
    Patent CFA, SFA, Popliteawr, Tibial arteries with no significant disease.
    Three vessel below knee runoff to ankle bilaterally.

    Procedure log:
    -RT & LT groin sterile field obtained
    -1 groin anesthetized, 2% lidocaine given SQ
    -LFA cannulated with 4Fr sheath, using the Percutaneous stick method.
    -RT & LT arteriograms performed
    -Ivedp 22
    -ABD AO
    -RT & LT lower extremity angio performed
    -procedure completed

  2. #2
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    Quote Originally Posted by coders_rock! View Post
    Please help guide with coding this cath report. I can use your help, thanks.

    Vessel Angiograply Findings
    The coronary tree has a right dominance.
    LM: Moderated ectasia of the Left Mail.
    LAD: Moderated ectasia of the proximal LAD. There is a 40%-50% stenosis in the mid LAD.
    Mild diffuse disease in the distal LAD
    Ramus I: Moderated diffuse disease in the ramus intermedius. Mild ectasia of the ramus intermedius.
    LCX: Mild diffuse disease in the mid circumflex.
    RCA:Mild extasia of the proximal RCA. There is a 40% stenosis in the proximal RCA. At the bend of the proximal RCA. Moderated extasia of the mid RCA. Severe ectasia of the distal RCA. Mild diffuse disease in the PDA of the RCA.

    Left Ventriculography
    EF: 45% EF Method: EF estimated

    Left Ventriculography Findings
    Normal left ventricular function (hand injection)

    Other Angiographic Findings
    Peripheral Angiograply:
    Tortuous iliac arteries with no significant disease.
    Patent CFA, SFA, Popliteawr, Tibial arteries with no significant disease.
    Three vessel below knee runoff to ankle bilaterally.

    Procedure log:
    -RT & LT groin sterile field obtained
    -1 groin anesthetized, 2% lidocaine given SQ
    -LFA cannulated with 4Fr sheath, using the Percutaneous stick method.
    -RT & LT arteriograms performed
    -Ivedp 22
    -ABD AO
    -RT & LT lower extremity angio performed
    -procedure completed
    You need to give a full report that's better than this. I see a left heart cath, and a bilateral peripheral run-off. But where was the catheter placed for the peripheral run-off? Sorry, but not enough information.
    Thanks,
    Jim Pawloski, CIRCC

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