CARDIAC CATH LAB REPORT
History: The patient is a 44-year-old with a family history of coronary artery disease. He is a heavy cigarette smoker with dependence. He had an electrocardiogram showing an old anterior septal myocardial infarction. MRI showed a fixed anterior defect. He is referred today for coronary angiography due to episodes of chest pain.
Description of the Procedure: The patient arrived in the procedure room and was administered 100 mcg Fentanyl and 2 mg Versed. 1% lidocaine was infiltrated over the right femoral artery. A 6-French sheath was placed in the right femoral artery. Diagnostic coronary angiography was performed with a 6-French JL-4 and 6-French JR-4 diagnostic catheters. There was no aortic stenosis on left heart pullback. There was no significant obstructive coronary artery in the right coronary artery, the left circumflex artery or left anterior descending coronary artery. There is a 10% to 20% stenosis in the distal left main.
Hemodynamic measurements were taken and repeated to evaluate hemodynamic response. Opening aortic pressure was 103/58. Following coronary angiography, the left ventricular pressure was 107/12.
Following coronary angiography, a 6-French pigtail catheter was placed in the left ventricle where left ventriculography was performed with 36 cc of contrast injected at 12 cc per second for 2 minutes. The left ventricular systolic function is normal. There are no regional wall motion abnormalities and no mitral regurgitation.
At the conclusion of the procedure, the catheter and sheath were removed and Angio-Seal plug was deployed.
Impression: There is no significant obstructive coronary artery disease. There is plaque in the distal left main, but no significant obstruction.
Left ventricular systolic function is normal. There is no evidence of previous anterior wall myocardial infarction.
Plan: Patient is urged to discontinue smoking and was referred to a smoking cessation program. Continue daily low-dose aspirin therapy. Nitroglycerin as needed.
Select the appropriate CPT and ICD-10-CM codes.
A) 93460, 93566, 93463, I25.9, I25.2
B) 93453, 93463, R07.9, F17.200, Z82.49, Z79.82
C) 93460, 93566, R07.9, F17.200, Z82.49, Z79.82
D) 93453, 93566, R07.9, F17.200, I25.2

Preoperative Diagnosis: Worsening Effort Angina with Severe Left Ventricular Failure

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