Medical Coding Expert. Instructions: Assign ICD-10 and CPT/HCPCS codes for this surgical pathology case study.
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Indication: Chest Pain
Procedure: Myocardial Perfusion, Multiple Study Spect w/ Wall Motion and Ejection Fraction
Indication: The patient is a 63-year-old woman with a history of chest pain. The patient also has a history of diabetes mellitus and reports a cough on exertion and back pain. Evaluate myocardial perfusion.
Following the intravenous administration of 10.37 mCi of Tc-99m Sestamibi, SPECT images of the heart were obtained. Immediately following the completion of an injection of 0.4 mg of Lexiscan, the patient was injected with 31.83 mCi of Tc-99m Sestamibi and SPECT images of the heart at stress were obtained approximately 45-60 minutes later. Gated images were obtained. The stress EKG portion of the study is separately interpreted and reported by the Division of Cardiology. This study was supervised and viewed for interpretation by both the staff physician and resident physician. This patient’s stress myocardial perfusion scan was obtained in the supine and prone positions. If one were to interpret this patient’s supine post stress images with her resting ones, reduced intensity of radiotracer is demonstrated within apical inferior wall, inferior wall, and apex. When these regions are viewed on this patient’s post stress prone myocardial perfusion images normalization of radiotracer occurs within them.
Mild reversible findings are demonstrated on this patient’s supine post stress/rest images in the mid inferior lateral wall and apical anterior septum. When these regions are viewed on this patient’s post stress prone images normalization of radiotracer also occurs within them. The left ventricular cavity appears slightly larger on post stress than rest images. Gated wall motion images reveal all walls to move and thicken normally. The quantitative gated SPECT left ventricular left ventricular ejection fraction is calculated to be approximately 66%.
- No reversible perfusion defect is demonstrated on this study to identify a site of stress-induced ischemia when one interprets this patient’s supine and prone post stress myocardial perfusion images with his resting ones.
- The left ventricular cavity appears slightly larger on post stress than rest images. This finding is indicative of stress-induced left ventricular dilatation. Stress-induced left ventricular dilatation may be secondary to stress-induced subendocardial ischemia; a finding that has been reported to occur in individuals with hypertension, a dilated cardiomyopathy, and in patients with balanced ischemia (left main/multivessel disease).
- Normal gated wall motion images.
- The quantitative gated SPECT left ventricular ejection fraction is calculated to be approximately 66%.