For this question I need the ICD-10-CM, CPT, or ICD-10-CPS medical codes AND a brief description on how to look them in

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For this question I need the ICD-10-CM, CPT, or
ICD-10-CPS medical codes AND a brief description
on how to look them in a the appropriate coding books for the
Primary Diagnosis, Primary procedure, Secondary Diagnosis, and
Secondary procedure for this case study.
16-3. CASE STUDY
History and Physical CC: Abnormal adenosine myocardial perfusion
SPECT study. HPI: This 80-year-old man with known coronary artery
disease who is status post bypass surgery and subsequent balloon
angioplasty and angioplasty with stent procedures was referred for
cardiac catheterization because of recurrent chest pain. His last
coronary interventional procedure about 8 years ago involved the
deployment of two 3.0-mm Duet stents in the proximal right coronary
artery. Recently, he developed recurrent angina. An adenosine
perfusion SPECT study showed a left ventricular ejection fraction
of 38% and evidence of reversible ischemia in the inferolateral and
anterolateral walls. On the basis of these findings, he was
referred for cardiac catheterization. He was admitted to the
hospital for cardiac cath and possible intervention. Past medical
history: CAD, previous MI, dyslipidemia, GERD, gout, and
hypertension. He had a stroke 3 years ago. Past surgical history:
CABG, PTCA, left total knee replacement, and left carotid
endarterectomy. Social history: History of tobacco many years ago.
Social alcohol. Family history: Positive family history for CAD.
Allergies: NKDA. Review of Systems: Constitutional: No fever or
chills. No change in weight. Appetite is good. Neuro: No headache,
seizures, or syncope. No dizziness. HEENT: No diplopia or hearing
loss. CV: Decreased exercise tolerance, occasional chest pain with
SOB. Respiratory: No cough or hemoptysis. GI: Negative. GU: Benign.
Skin/Skeletal: No rashes, pain, or joint stiffness. Physical
Examination: Vitals: Stable. General: NAD. Some anxiety about
upcoming procedure. HEENT: Normocephalic, atraumatic. Neck is
supple with no lymphadenopathy. PERRL. EOMI. Chest: CTA
bilaterally. CV: RRR. S1 and S2 normal. Abd: No tenderness,
guarding, or rigidity. Bowel sounds are present. Ext: WNL.
GU/Rectal: Deferred. Skin/Musculoskeletal: WNL. Neuro: Alert and
oriented. Cranial nerves intact. Gait is normal Assessment/Plan:
Patient was admitted for cardiac catheterization and possible PCI
depending on the findings. Final Report Cardiovascular Diagnostic
Laboratory Invasive/Interventional Cardiology Procedure Report:
Procedures performed: 1. Vascular access. 2. Coronary
arteriography. 3. Percutaneous coronary intervention. 4.
Iliofemoral arteriogram. Pt height (in/em): 67.0/170.2. Pt weight
(lb/kg): 226.6/103.0. Fluoro time (min): 24.4. History: The patient
is an 80-year-old man with known coronary artery disease s/p CABG
(LAD and SVG to LADD). Thereafter, he underwent a balloon
angioplasty procedure. Subsequently, he experienced an inferior MI.
Cardiac catheterization then showed a totally occluded RCA and
patent grafts. Two 3.0 ACS Duet stents were deployed in the
proximal RCA. He recently developed recurrent angina. An adenosine
myocardial perfusion SPECT study showed an LVEF of 38% and
partially reversible defects of the inferolateral and anterolateral
walls. His risk factors for CAD include remote tobacco use,
dyslipidemia, and hypertension. He had a minor stroke 3 years ago
and a left carotid endarterectomy. Procedure description: After the
usual sterile prep and drape, the site was locally anesthetized and
vascular sheaths were inserted as described below. With use of the
catheters described below, coronary angiography was performed in
multiple projections. With the catheters and devices described
below, percutaneous coronary intervention (PCI) with drug-eluting
stent deployment in the RCA and LCX was performed with appropriate
anticoagulation. The attending physician performed the procedure
and interpreted the results. Impression: Coronary angiography: Mild
coronary calcification. Right dominant circulation. Normal LM.
Totally occluded proximal LAD distal to the first septal branch.
The distal LAD was visualized by injection of LIMA graft.
Large-caliber LCX with proximal 90% stenosis. The LCX gave origin
to a medium-caliber bifurcating CXM that has a proximal 70%
stenosis. Large-caliber dominant RCA with proximal 90% stenosis.
Previously deployed RCA stents were patent with mild in-stent
restenosis. The distal RCA gave origin to a large-caliber RPDA with
mild proximal disease. The large-caliber RPLB has a proximal 70%
stenosis. Widely patent LIMA graft to the LAD. The distal LAD is a
small-caliber vessel with a 60% stenosis. There is extensive
retrograde perfusion to the LAD diagonal that has an ostial 90%
stenosis. Totally occluded SVG to LADD. Successful proximal RCA PCI
with drug-eluting stent deployment with a 3.5 × 18-mm Cypher stent
converting the 90% stenosis to 0% residual. Successful proximal LCX
PCI with drug-eluting stent deployment with a 2.5 × 28-mm Cypher
stent converting 90% stenosis to 0% residual. Recommendations:
Long-term ASA and Plavix × 1 year. Continued aggressive medical
management. Will follow renal function post procedure. Procedure
Data Contrast: Visipaque 270.0 cc, vascular. Devices: Stents:
Implanted Implanted Manufacturer Cordis Cordis Model Cypher Cypher
Model # 3.5 × 18 2.5 × 28 Serial # AAAAA BBBBB Vessel RCA LCx
Vascular Access: Vessel art: Femoral Vessel side: Right Access
type: Percutaneous puncture Sheath size: 6 Sheath count: 1 Vascular
closure: Angioseal device Coronary Arteriography: Indications:
Primary indication: angina, stable. Catheters: Obs #1 Obs #2 Obs #3
Vessel LM RCA Other (see comment) Catheter size 6 6 6 French
Catheter shape JL4 JR4 JR4 Engagement Good Good Good Comment: SVG
to LADD totally occluded. Obs #4 Vessel LIMA Catheter size 6 French
Catheter shape IMA Engagement Good Coronary Anatomy: Dominance:
Right Territory supplied LAD system: Large Territory supplied Cx
system: Large Territory size RCA system: Large Summary Results:
Preliminary recommendation: Proceed with PCI. Percutaneous Coronary
Intervention: Indications: Primary indication: angina, stable.
Target lesion: Vessel type: Native coronary Segment name: pRCA
proximal RCA Location in segment: Proximal Percent stenosis, %: 90
Stenosis length, mm: 15 Reference vessel diameter, mm: 3.5 Lesion
type: De novo TIMI flow: 3 Territory distal to lesion: Large Patent
graft nearby: Stenosis of ungrafted vessel Distal vessel
graftability: Poor Could patient withstand CAB? Poor candidate PCI
Sequence: Obs #1 Obs #2 Obs #3 Device type GC guide catheter GW
guidewire BAL balloon Description/model Launcher JR4 Pilot 50
Voyager Size 6 inches/French Intracoronary diameter, mm 2.5
Intracoronary length, mm 9 Successful Yes Yes Yes #: 2
inflations/passes Maximum pressure 8 atm Maximum duration, mm:ss
1.00 Obs #4 Device type DEST drug-eluting stent Description/model
Cypher Intracoronary diameter 3.5 mm Intracoronary length, mm 18
Successful Yes # 1 inflation/pass Maximum pressure 18 atm Maximum
duration 1.00 mm:ss Final Result: Observation Final (residual)
stenosis, % 0 TIMI flow 3 Procedural antithrombotic Rx Bivalirudin
Procedural antiplatelet Rx Oral agents only Procedural ACT sec 400
Final PCI result Successful Percutaneous Intervention: Indications:
primary indication: angina, stable Target lesion: Vessel type:
Native coronary Segment name: pCIRC proximal circumflex Location in
segment: Proximal Percent stenosis, %: 90 Stenosis length, mm: 20
Reference vessel diameter, mm: 2.5 Lesion type: De novo TIMI flow:
3 Territory distal to lesion: Large Patent graft nearby: Stenosis
of ungrafted vessel Distal vessel graftability: Poor Could patient
withstand CAB? Poor candidate 4 PCI sequence: Obs #1 Obs #2 Obs #3
Device type GC guide catheter GW guidewire BAL balloon
Description/model Launcher AL2 Pilot 50 Voyager Size 6
inches/French Intracoronary diameter, mm 2.5 Intracoronary length,
mm 20 Successful Yes Yes Yes #: 2 inflations/passes Maximum
pressure 16 atm Maximum duration 1.00 mm:ss Obs #4 Device type DEST
drug-eluting stent Description/model Cypher Intracoronary diameter,
mm 2.5 Intracoronary length, mm 28 Successful Yes #: 2
inflations/passes Maximum pressure 19 atm Maximum duration 1.00
mm:ss Final Result: Observation Final (residual) stenosis, % 0 TIMI
flow 3 Procedural antithrombotic Rx Bivalirudin Procedural
antiplatelet Rx Oral agents only Procedural ACT, sec 400 Final PCI
result Successful Iliofemoral Arteriogram: Indications: Primary
indication: arterial stricture/stenosis. No right iliac disease.
Angioseal deployed. Discharge Summary Diagnoses/Problems: 1.
Coronary artery disease. 2. Stable angina pectoris. 3. Status post
coronary artery bypass graft surgery many years ago with a left
internal mammary artery graft to the left anterior descending and a
saphenous vein graft to the left anterior descending diagonal
coronary arteries. 4. Status post angioplasty of the right coronary
artery left circumflex and right posterior descending coronary
arteries. 5. Status post inferior wall myocardial infarction
complicated by ventricular fibrillation. 6. Status post
percutaneous transluminal coronary angioplasty with stent
deployment in the right coronary artery. 7. Hypertension. 8.
Hyperlipidemia. 9. Status post cerebrovascular accident. 10. Status
post left carotid endarterectomy. 11. Gastroesophageal reflux
disease. 12. Gout. 13. Left total knee replacement. 14. Left eye
enucleation status post trauma. 15. Right eye cataract
extraction.
Procedures: 1. Left heart cardiac catheterization. 2.
Percutaneous transluminal coronary angioplasty with drug-eluting
stent deployment in the right coronary artery. 3. Percutaneous
transluminal coronary angioplasty with drug-eluting stent
deployment in the proximal left circumflex coronary artery. 4.
Right iliac angiogram with application of an Angioseal closure
device. History, Major Findings, and Hospital Course: Brief
history: This 80-year-old man with known coronary artery disease
who is status post bypass surgery and subsequent balloon
angioplasty and angioplasty with stent procedures was referred for
cardiac catheterization because of recurrent chest pain. His last
coronary interventional procedure about 8 years ago involved the
deployment of two 3.0-mm Duet stents in the proximal right coronary
artery. Recently, he developed recurrent angina. An adenosine
perfusion SPECT study showed a left ventricular ejection fraction
of 38% and evidence of reversible ischemia in the inferolateral and
anterolateral walls. On the basis of these findings, he was
referred for cardiac catheterization. He was admitted to the
hospital and underwent coronary angiography on that same day.
Coronary angiography demonstrated the following: There was mild
coronary calcification. The distribution was right dominant. The
left main coronary artery was normal. The proximal LAD was totally
occluded just distal to the first septal branch. The distal LAD was
visualized by injection of the LIMA graft. The left circumflex was
a large-caliber vessel with proximal 90% stenosis. The left
circumflex gave origin to a medium-caliber bifurcating circumflex
marginal that had a proximal 70% stenosis. The right coronary
artery was a large-caliber dominant vessel with proximal 90%
stenosis. Previously deployed RCA stents were patent with mild
in-stent restenosis. The distal right coronary artery gave origin
to a large-caliber right posterior descending artery that had mild
proximal disease. The large-caliber right posterolateral branch had
a proximal 70% stenosis. The LIMA graft to the LAD was widely
patent. The distal LAD was a small-caliber vessel with a 60%
stenosis. There was also extensive retrograde perfusion to the more
proximal LAD and a medium-caliber LAD diagonal that had an ostial
90% stenosis. The saphenous vein graft to the LAD diagonal was
totally occluded. On the basis of these findings, we elected to
proceed with percutaneous intervention on both the right coronary
artery and the left circumflex coronary artery. We first performed
intervention on the proximal right coronary artery with
drug-eluting stent deployment with a 3.5 × 18-mm Cypher stent that
converted to 90% stenosis to 0% residual. We then proceeded with
intervention on the proximal left circumflex with drug-eluting
stent deployment with a 2.5 × 28-mm Cypher stent that converted to
90% stenosis to 0% residual. His postangioplasty stent course was
uncomplicated, and he was discharged home in stable condition.
Discharge condition: Stable. Discharge Medications: Aspirin 81 mg
every day Lipitor 10 mg nightly Plavix 75 mg every day Irbesartan
300 mg every evening Nexium 40 mg every day Probenecid/colchicine
500/0.5 mg 1 tablet by mouth 2 times a day Nitroglycerin 0.4 mg
sublingual as needed for chest pain Fish oil 1000 mg a day
Metoprolol 75 mg every morning and 50 mg every evening.
Follow-up Care: The patient will be seen in follow-up with the
cardiologist. Progress Note Patient is recovering from PCI to the
proximal RCA and circumflex. No evidence of groin hematoma. Patient
can be discharged home later today.