Audit Report 6.1 Echocardiogram Report LOCATION: Inpatient, Hospital PATIENT: Ma
ID: 122012 • Letter: A
Question
Audit Report 6.1 Echocardiogram Report LOCATION: Inpatient, Hospital
PATIENT: Marilyn Aschoff
ATTENDING PHYSICIAN: David Barton, MD RADIOLOGIST: Morton Monson, MD
INDICATION: Shortness of breath and atrial fibrillation
FINDINGS bymeansof2-DandM-modeechocardiography:
CARDIAC CHAMBERS: The left atrium was mildly dilated and measured 4.4 cm. There was no evidence of atrial thrombi. The aortic root dimensions were within normal limits. The left ventricle was normal in size. There was mild concentric left ventricular hypertrophy. There was severe diffuse hypokinesis. The apex was kinetic. The overall ejection fraction was about 15%-20%. The right atrium was mildly dilated. The right ventricle was normal in size.
VALVES: The mitral valve has mild fibrocalcific changes, but more so the posterior leaflet, with mitral annulus calcification. The mitral valve excursion was adequate. There was aortic sclerosis, without significant stenosis. The tricuspid valve was grossly normal. The pulmonic valve was not well visualized.
DOPPLER AND COLOR DOPPLER INTERROGATION reveals the presence of severe mitral and tricuspid insufficiency. The calculated right ventricular systolic pressure was 42 mmHg.
CONCLUSION: 1. Severe left ventricular dysfunction. 2. Severe mitral and tricuspid insufficiency. 3. Mild to moderate pulmonary hypertension.
RECOMMENDATIONS: 1. Digitalization. 2. Afterload reducing agents. 3. Diuretics. 4. If this patient is labile, then bilateral heart catheterization should be considered. Although the LV function is severely reduced, part of that could be due to the fact that she has been tachycardic for a long period of time, i.e., can be tachycardia induced.
One of the codes is not reported for this case. Indicate the missing code.
Echocardiography, 93306-26
PROFESSIONAL SERVICES: ICD-10-CM DX: Ventricular dysfunction, I51.9; Mitral valve insufficiency with tricuspid insufficiency, I08.1
MISSING CODE:__________________
Explanation / Answer
PROFESSIONAL SERVICES: ICD-10-CM DX: Ventricular dysfunction, I51.9; Mitral valve insufficiency with tricuspid insufficiency, I08.1
MISSING CODE:__________________
Ans : The missing ICD 10 code is 127.2. It involves primary pulmonary hypertension.
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