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Question: assign icd10cm code to operative report description left heart cath...

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Assign ICD-10-CM code to operative report.

Description: Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.
EXAM: Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.

REASON FOR EXAM: Abnormal stress test and episode of shortness of breath.

PROCEDURE: Right common femoral artery, 6-French sheath, JL4, JR4, and pigtail catheters were used.

FINDINGS:
1. Left main is a large-caliber vessel. It is angiographically free of disease,
2. LAD is a large-caliber vessel. It gives rise to two diagonals and septal perforator. It erupts around the apex. LAD shows an area of 60% to 70% stenosis probably in its mid portion. The lesion is a type A finishing before the takeoff of diagonal 1. The rest of the vessel is angiographically free of disease.
3. Diagonal 1 and diagonal 2 are angiographically free of disease.
4. Left circumflex is a small-to-moderate caliber vessel, gives rise to 1 OM. It is angiographically free of disease.
5. OM-1 is angiographically free of disease.
6. RCA is a large, dominant vessel, gives rise to conus, RV marginal, PDA and one PL. RCA has a tortuous course and it has a 30% to 40% stenosis in its proximal portion.
7. LVEDP is measured 40 mmHg.
8. No gradient between LV and aorta is noted.

Due to contrast concern due to renal function, no LV gram was performed.

Following this, right common femoral angiogram was performed followed by StarClose closure of the right common femoral artery.

IMPRESSION:
1. 60% to 70% mid left anterior descending stenosis.
2. Mild 30% to 40% stenosis of the proximal right coronary artery.
3. Status post StarClose closure of the right common femoral artery.

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