CARDIAC CATHETERIZATION REPORT

A patient with the chief complaint of chest pains undergoes a cardiac catheterization with stenting and a follow-up x-ray. Code these services.

The report does not document the initial placement of the catheter, which was performed by another physician and reported with 93458.

LOCATION:	Outpatient, Hospital
PATIENT:	Bernie Lieberwitz
SURGEON:	David Barton, MD

PROCEDURES PERFORMED: Left heart catheterization, selective coronary angiography and left ventriculography

INDICATION:	Chest pain and abnormal Cardiolite stress test
COMPLICATIONS:	None

RESULTS:

1. HEMODYNAMICS: The left ventricular pressure before the LV (left ventricle)-gram was 117/1 with an LVEDP of 4. After the LV-gram, it was 111/4 with an LVEDP of 10.The aortic pressure on pullback was 111/17.
2. LEFT VENTRICULOGRAPHY: The left ventriculography showed that the left ventricle was normal in size. There were no significant segmental wall motion abnormalities. The overall left ventricular systolic function was normal, at better than 60%.
3. SELECTIVE CORONARY ANGIOGRAPHY:
4. RIGHT CORONARY ARTERY: The right coronary artery is a medium- to large-size dominant artery that has about 80% to 90% proximal/mid eccentric stenosis. The rest of the artery has only mild surface irregularities. The PDA (posterior descending artery) and the posterolateral branches are small in size and have only mild surface irregularities.
5. LEFT MAIN CORONARY ARTERY: The left main has mild distal narrowing.
6. LEFT CIRCUMFLEX ARTERY: The left circumflex artery was a medium-size nondominant artery. It gave rise to a very high first obtuse marginal/intermedius, which was a bifurcating medium-size artery that has only mild surface irregularities. The second obtuse marginal was also a medium-size artery at about 20% to 30% proximal narrowing. After that second obtuse marginal, the circumflex artery was a small-size artery that has about 20% to 30% narrowing, a small aneurysmal segment. After that, it continued as a small third obtuse marginal that has mild atherosclerotic disease.
7. LEFT ANTERIOR DESCENDING CORONARY ARTERY: The left anterior descending artery was a medium-size artery that is mildly calcified. It gave rise to a very tiny first diagonal that has mild diffuse atherosclerotic disease. Right at the origin of the second diagonal, the LAD (left anterior descending coronary artery) has about 30% narrowing. The rest of the artery was free of significant obstructive disease. The second diagonal was also a small-caliber artery that has no significant obstructive disease.

CONCLUSION:

1. Normal overall left ventricular systolic function.
2. Severe single vessel atherosclerotic heart disease.

RECOMMENDATION: Angioplasty stent of the right coronary artery

SERVICE CODE(S):

ICD-10-CM DX CODE(S):