Assign the appropriate dx codes for the following:
1. Congenital CAD -
2. Atherosclerosis of autologous vein coronary artery bypass graft-
3. Atherosclerosis of nativecoronary artery of transplanted heart with angina pectoris-
4.
Case : 1
The patient is a 67-year-old male who was transferred from a local community
hospital where he was admitted six days ago with chest pain, shortness of
breath, elevated cardiac enzymes, and EKG changes indicating an anterolateral
ST elevation myocardial infarction. The patient subsequently underwent a
cardiac catheterization, which revealed significant four-vessel disease. He was
transferred here for a coronary artery bypass procedure.
Past History: Hypertension, Type 2 diabetes (on insulin), hypercholesterolemia
and having a chronic history of Pickwickian syndrome, carcinoma of the sigmoid
colon which was treated with resection of the sigmoid colon and chemotherapy
five years ago (the patient has had no recurrence and is currently not being
treated).
Allergic to latex and IV contrast
Social History: He quit smoking but still continues to be a alcohol dependent. BMI
42.5
Operative Report Preoperative Diagnosis: CAD Postoperative Diagnosis: CAD
Procedure: CABG ×4; saphenous vein graft to the obtuse marginal, diagonal artery
and posterior descending artery; left internal mammary artery to the left anterior
descending artery; cardiopulmonary bypass.
of Procedure: After obtaining adequate anesthesia, the patient was prepped and
draped in the usual fashion. A primary median sternotomy incision was made, and
the pericardium was opened. The left internal mammary artery was dissected as a
pedicle using electrocautery and small hemoclips at the same time that the greater
saphenous vein was harvested endoscopically from the left lower extremity.
Cardiopulmonary bypass was instituted and the patient was taken to a mild degree
of hypothermia.
The aorta was cross-clamped and electrical arrest effect was administered viacold
blood cardioplegia. The saphenous vein graft was placed end-to-side with the
posterior descending artery, then a separate graft was placed to the obtuse
marginal and finally a separate graft was placed to the diagonal artery. Each
anastomosis was done with running 7-0 Prolene suture and verified no bleeders
were present. The left internal mammary artery was subsequently brought through a
subthalamic tunnel and placed end-to-side with the left anterior descending
coronary artery.
Following completion of the grafts, warm blood cardioplegia was administered.
During this time, two atrial and ventricular pacing wires were attached to the heart’s
surface; in addition, mediastinal tubes were also placed. The cross clamps were
released following this, and sinus rhythm returned spontaneously. The patient was
weaned from cardiopulmonary bypass without incident.
After all grafts were checked for diastolic flow, which revealed no problems, the
incisions were closed. The patient was taken to the recovery room in good condition
and will be monitored in the intensive care unit. The procedure took approximately 5
hours.
POD # 1 Pt was resting and no complications noted.
POD # 2 Pt started, developing SOB, respiratory distress PCO2 -65% , SpO2 <
88% , RR 28 , Quickly required BipaP . Pt recovered within 24 hrs .
Impression and Plan: Anterolateral myocardial infarction, coronary artery disease,
diabetes mellitus, and hypercholesterolemia
Pdx ______ POA ____
Sdx___________ POA ____
Sdx___________ POA ____
Sdx___________ POA ____
Sdx___________ POA ____
Sdx___________ POA ____
Sdx___________ POA ____
Sdx___________ POA ____
Sdx___________ POA ____
Sdx___________ POA ____
SVG-3
LIMA-1
PCS _______021209W_______________
PCS _____________02100Z9______________
PCS ____________06BQ4ZZ___________________
PCS ______________________
PCS ___________________________
Query opportunity? Yes/NO
What was the condition for query? ----
Case: 2
. A 65 yrs old male with severe calf claudication developed an ulcer on the rt foot and was
admitted to the hospital for percutaneous interventional procedure. The pt is a smoker , DM
type I, and dyslipidemia. Diagnostic angiography confirmed complete occlusion of the Rt
superficial femoral artery and he underwent balloon angioplasty with stent placement using a
drug coated balloon. Post procedural imaging showed that the blood flow had been restored.
Pdx ______ POA ____
Sdx___________ POA ____
Sdx___________ POA ____
Sdx___________ POA ____
Sdx___________ POA ____
Sdx___________ POA ____
Sdx___________ POA ____
PCS ___________________________
Case: 3
80yrs old female with corornary artery disease of 90% occlusion of left anterior descending
artery and 100% occlusion of diagonal branch.
Double aorto-coronary artery bypass, open approach (left internal mammary artery to
left anterior descending; Left greater saphenous vein to diagonal, open
harvesting) (Do not code use of cardiopulmonary bypass equipment)
Ans : Pdx ______ POA ____
Sdx___________ POA ____
Sdx___________ POA ____
Sdx___________ POA ____
Sdx___________ POA ____
Sdx___________ POA ____
Sdx___________ POA ____
PCS ___________________________
Case: 4
Brief Description of Procedure:
Right greater saphenous vein was harvested from lower extremity with percutaneous
endoscopic harvesting technique.
Sternotomy was performed. Left internal mammary artery was taken down with
electrocautery and fine Hemoclips. Pericardium was opened. The patient was placed
on cardiopulmonary bypass. The LIMA was dissected as a pedicle.
The saphenous vein graft was placed end-to-end with the
posterior descending artery then a separate graft was placed to obtuse
marginal. The LIMA was subsequently placed end-to-side with the left anterior descending
artery.
Patient weanedfrom cardiopulmonary bypass. Incision closed and patient wastaken to
recovery in good condition.
CABGX3 – Reverse SVG from aora to OM & PDA. LIMA to LAD, cardiopulmonary bypass
Ans:
Case: 5
The patient came to the hospitalwith unstable angina. He was
taken emergently to the cardiac cath lab and underwent left
heart cath Judkins technique, coronary angiography, left
ventriculogram via femoralartery puncture. (Low osmolar contrast
used) Findings were near total occlusion of the RCA and
80% stenosis of the left circumflex. Decision was made
to do a PTCA and stent insertion. The RCA had
angioplasty reducing the stenosis to 10%; a drug eluting
stent was then placed in the RCA. The left circumflex had
angioplasty with placement of a stent. He tolerated the
procedure well. He was monitored post operatively. He was
instructed on smoking cessation related to his nicotine
addiction, smoking 2 packs of cigarettes per day. Final
diagnosis is unstable angina due to coronary arteriosclerosis.
He will follow up in the office in two weeks.
