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What do I focus on and what are codes for this operative report,coronary artery angiogram? LOCATION: Outpatient, Hospital PATIENT: Marvin Cole SURGEON: Marvin Elhart, M.D.
What do I focus on and what are codes for this operative report,coronary artery angiogram?
LOCATION: Outpatient, Hospital PATIENT: Marvin Cole SURGEON: Marvin Elhart, M.D. INDICATION: Native atherosclerotic heart disease PROCEDURE PERFORMED: Angiography of the right coronary system BRIEF HISTORY: 61-year-old patient with known atherosclerotic heart disease with previous bypass surgery with graft failure. The patient has end stage renal disease and is on hemodialysis. He underwent angioplasty of a totally occluded ramus stent and he is being brought back today for elective attempt to recanalize his chronically totally occluded right coronary artery using a front-runner. The patient understands the procedure, indications, alternatives, all the potential risks and complications, and consents. PROCEDURE: The patient was brought to the cath lab. He underwent procedure via right femoral artery access. At the end, the sheath was left in place. The patient was sent to the ICU in stable condition. FINDINGS: Coronary angiography of the right coronary artery system was performed revealing severely diseased vessel with subtotal occlusion proximal and total occlusion mid. There is right-to-right and left-to-right collaterals that were documented in the past. ramus. Left coronary injections were performed and revealed widely patent left vein and a patent (Documentation would be required here to describe the entire procedure. The lack of documentation would create a liability and would not be billable until there was an addendum to support the procedure performed. An addendum should be dated and signed by the provider and it should include the reason for the addendum.)
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