How and what are the CPT and ICD-10 codes for this Operative Report,Ptca Joints LOCATION: Outpatient, Hospital

How and what are the CPT and ICD-10 codes for this Operative Report,Ptca

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Joints LOCATION: Outpatient, Hospital PATIENT: Harvey Goodrun SURGEON: James Noonar, M.D. INDICATION: Native atherosclerotic heart disease. PROCEDURE: PTCA OF 65% OCCLUDED RCA PROCEDURE: After the patient was heparinized, we advanced a multipurpose guide and a BMW guide across the stent immediately. I advanced a 3.5 balloon, showing flow, and there was no evidence of thrombosis distally, which was excellent. For that reason, we decided to go ahead and dilate with a 3.5 balloon. That gave us a lot of watermelon seeding. For that reason, we exchanged to a cutting balloon and we performed inflations in multiple areas up to 10-12 atmospheres. I did advance the wire all the way retrograde at the area of total occlusion and I used the backup support of a 2.0 balloon to see if I can cross it in a retrograde fashion; that did not work. I used a 2.0 balloon to inflate the PDA. Final angiographic views obtained revealed an excellent result. The vessel was recanalized. There was less than 30% diffuse stenosis in the stented segment and the PDA itself was widely patent. Please note that the native right coronary artery did have severe disease with subtotal occlusion proximally and total occlusion just distal to the ostium. Patient tolerated the procedure well and was transferred to the recovery area for observation in stable condition. PLAN: 1. Observation overnight. 2. I will seriously consider recanalizing this patient's native anatomy. His total occlusion segment is short and I might seriously consider doing that on Friday. This would achieve a dual supply to his right coronary artery, i.e., native and the vein graft. I think that might be a good option, especially in that this patient's vein graft certainly stands a high chance of recurrence. Joints LOCATION: Outpatient, Hospital PATIENT: Harvey Goodrun SURGEON: James Noonar, M.D. INDICATION: Native atherosclerotic heart disease. PROCEDURE: PTCA OF 65% OCCLUDED RCA PROCEDURE: After the patient was heparinized, we advanced a multipurpose guide and a BMW guide across the stent immediately. I advanced a 3.5 balloon, showing flow, and there was no evidence of thrombosis distally, which was excellent. For that reason, we decided to go ahead and dilate with a 3.5 balloon. That gave us a lot of watermelon seeding. For that reason, we exchanged to a cutting balloon and we performed inflations in multiple areas up to 10-12 atmospheres. I did advance the wire all the way retrograde at the area of total occlusion and I used the backup support of a 2.0 balloon to see if I can cross it in a retrograde fashion; that did not work. I used a 2.0 balloon to inflate the PDA. Final angiographic views obtained revealed an excellent result. The vessel was recanalized. There was less than 30% diffuse stenosis in the stented segment and the PDA itself was widely patent. Please note that the native right coronary artery did have severe disease with subtotal occlusion proximally and total occlusion just distal to the ostium. Patient tolerated the procedure well and was transferred to the recovery area for observation in stable condition. PLAN: 1. Observation overnight. 2. I will seriously consider recanalizing this patient's native anatomy. His total occlusion segment is short and I might seriously consider doing that on Friday. This would achieve a dual supply to his right coronary artery, i.e., native and the vein graft. I think that might be a good option, especially in that this patient's vein graft certainly stands a high chance of recurrence.