Case -AUDIT REPORT T6.2 ANGIOPLASTY/STENT

Essay

Case
-AUDIT REPORT T6.2 ANGIOPLASTY/STENT
LOCATION: Inpatient, Hospital
PATIENT: Matthew Logan
ATTENDING PHYSICIAN: Leslie Alanda,MD
SURGEON: James Noonar, MD
INDICATION: ASHD
PROCEDURES PERFORMED: Stenting of the LAD and angioplasty of the second marginal
ANGIOPLASTY AND STENT OF THE LEFT ANTERIOR DESCENDING ARTERY: Mach 2.5 guide was used. The patient received intravenous heparin. He was preloaded with Plavix. A BMW was advanced to the LAD. Thereafter, a 3.0 15 balloon was dilated into the LAD. Thereafter, a 3.0 24 Taxus stent was deployed at 15 atmospheres with good angiographic result and no residual stenosis.
ANGIOPLASTY OF IN-STENT RESTENOSIS OF THE SECOND MARGINAL OF THE LEFT CORONARY ARTERY: The BMW wire was advanced to the circumflex, and the stent was dilated with 2.5 20 Quantum Maverick balloon with good angiographic result and no residual stenosis. Distal to the stent, there was a lesion that has a remainder of 20% to 30%, and I was not willing to stent the small vessel that is going to be prone to re-stenosis like it had done previously.
T6.2:
SERVICE CODE(S): 92928, 92929______________________________________
ICD-10-CM DX CODE(S): I25.10_______________________________________
INCORRECT/MISSING CODE(S): _____________________________________