medical coding reimbursement

Case 1

PROCEDURES PERFORMED:  Coronary Angiography PROCEDURE: Informed consent was obtained from the patient, and a time-out was performed to verify the patient's identification and planned procedure.   After the Allen's test was used to confirm patency of the ipsilateral ulnar artery, the patient's right radial artery site was prepped and draped in sterile fashion, and anesthetized with 1% subcutaneous lidocaine using a 25 gauge needle.  The radial artery was then entered by through-and-through puncture with a 22G angiocath needle.  The needle was then removed, followed by slow withdrawal of the angiocatheter until blood return was seen, confirming intra-arterial position.  A sheath kit wire was then advanced, allowing for exchange of the angiocatheter for a 5-Fr hydrophilic sheath.  The sheath was then flushed with 2.5 mg of verapamil diluted in blood, followed by 50 units/kg (up to maximum of 5000 units) of heparin administered intravenously.  A 180 cm Radial Glide Wire (1.5 mm J) or Versicore wire was used for initial catheter advancement, and a 260 cm 0.035" J-wire was used for subsequent catheter removal.  Standard angiography was performed using 5 Fr JR4 diagnostic catheters to engage the left main (LM) and right coronary artery (RCA), respectively. After the catheter was removed over the J-wire, the existing sheath was withdrawn half-way out in preparation for removal.  A VascBand was positioned as appropriate, and 12 cc of air used to inflate the band during simultaneous complete removal of the sheath.  The amount of air was then adjusted as need to ensure hemostasis while ideally allowing patency of the radial artery as confirmed by pulse oximetry during transient ipsilateral ulnar artery occlusion.  No immediate complications.  Estimate blood loss: minimal.  Specimens: none. I reviewed the patient's pre-sedation assessment and vital signs, supervised and directed the moderate sedation with continuous face-to-face attendance.  My intra-service time was 38 min.  Please see procedure log or sedation record for more details.