PATIENT: Herbert Humphrey
SURGEON: Marvin Elhart, M.D.
RADIOLOGY: Morton Monson, M.D.
INDICATIONS: Aortic valve evaluation; considering that the stenosis was not well-documented angiographically
PROCEDURE PERFORMED: Transesophageal echocardiogram
DESCRIPTION OF PROCEDURE: The patient received 2 mg of Versed, and a transesophageal probe was advanced to the
lower part of the esophagus. We had good visualization of the heart. The mitral valve was thickened with slight prolapse, but
there was no significant regurgitation noted. The LV displayed normal size and normal function. The aortic root is normal in
size. The aortic valve is calcified with diffuse cusp excursions with still adequate opening. Valve area was variable in different
incidents varying from 1 to even above 2.
CONCLUSION: This transesophageal echo shows aortic valve disease however, it does not appear to be severe. It appeared
to be moderately stenotic, and considering the angiography and the hemodynamics, this patient does not need valve surgery
at this time.
ICD 10 code, CPT, HCPCS
The procedure done is transesophageal echo and the diagnosis is aortic valve disease.
ICD -10CM is international classification of diagnosis . The latest version is tenth . These codes are used by healthcare workers and insurance companies to mention a diagnosis .
ICD -10 -CM code of aortic valve disease is I35.9
CPR code is current procedural terminology . These codes are also used by health care workers and insurance companies to represent a procedure rather than writing the whole thing.
CPT code of transesophageal echo is 93313 and 93314 . 93313 is used to code for echocardiography transesophageal , real time with image documentation and placement of transesophageal probe . 93314 is used to denote echocardiography transesophageal , real time with image documentation , acquisition , interpretation and report only .
PATIENT: Herbert Humphrey SURGEON: Marvin Elhart, M.D. RADIOLOGY: Morton Monson, M.D. INDICATIONS: Aortic valve evaluation; considering...
Health Record Face Sheet Record Number: 70-50-77 Age: 53 Gender: Male Length of Stay: 2 Days Service Type: INPATIENT Discharge Status: To Home Diagnosis/Procedure: Idiopathic Dilated Cardiomyopathy DISCHARGE SUMMARY PATIENT NAME: HUGH ACUTE ADMISSION DATE: 06-23-XX DISCHARGE DATE: 06-25-XX DISCHARGE DIAGNOSIS: 1. Idiopathic dilated cardiomyopathy, uncertain etiology. 2. Left bundle branch block. 3. Normal coronary arteries and normal hemodynamics. PROCEDURES: Cardiac catheterization. HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old male admitted for evaluation of grossly abnormal Thallium test....