Lesson 5 inpatient Coding Capstone Project 1
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14
Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-PCS
code(s).
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Patient: Hillary Rominey
DATE OF STUDY: 02/22/2018
ORDERING PHYSICIAN: Harrison Brady, MD
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DATE OF INTERPRETATION OF STUDY:
Echocardiogram was obtained for assessment of left ventricular function. The patient has been admitted with diagnosis of syncope.
Overall, the study was suboptimal due to poor sonic window.
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FINDINGS:
1. Aortic root appears normal.
2. Left atrium is mildly dilated. No gross intraluminal pathology is recognized, although subtle abnormalities could not be excluded.
Right atrium is of normal dimension.
3. There is echo dropout of the interatrial septum. Atrial septal defects could not be excluded.
4. Right and left ventricles are normal in internal dimension. Overall left ventricular systolic function appears to be normal. Eyeball
ejection fraction is around 55%. Again, due to poor sonic window, wall motion abnormalities in the distribution of lateral and apical wall
could not be excluded.
5. Aortic valve is sclerotic with normal excursion Color flow imaging and Doppler study demonstrates trace aortic regurgitation,
6. Mitral valve leaflets are also sclerotic with normal excursion. Color flow imaging and Doppler study demonstrate trace to mild
degree of mitral regurgitation.
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