Read the following medical report for an echocardiography study,then assign the correct ICD- 10-CM and CPT codes.
PROCEDURE NOTE
Patient: Adrian Babb
DOB: 06/11/1933
Hospital #: 32116897
Physician: Jason Finkle, DO
Date: July 15, 20XX
CLINICAL INDICATION: This is an 82-year-oldfemale recently presenting to Memorial Hospital with congestiveheart failure and new onset atrial fibrillation. She is here forassessment of mitral regurgitation after treatment with Betapaceand reversion to sinus rhythm. However, the patient is now back inatrial fibrillation with moderate to fast response and is stilltaking Betapace and Coumadin.
STUDIES PERFORMED: Evaluation includes 2-Dtransthoracic echocardiography, color-flow imaging, and Dopplerexam, and is technically adequate.
IMPRESSION:
1. Technically adequate study.
2. Overall left ventricular size is mildly dilated with normal wallthickness with diastolic function to assess because of atrialfibrillation. Overall systolic function appears to be at the lowerlimit of normal with an ejection fraction of 50 percent, thoughevaluation is somewhat difficult because of the fast irregularrhythm. Segmental evaluation reveals no gross abnormality, thoughthe septum is difficult to assess in terms of its function and theposterior wall is not seen. However, other walls appear to contractnormally.
3. Right ventricular size is normal, with normal wall thickness andnormal overall right ventricular function.
4. There is mild right atrial enlargement and moderate left atrialenlargement.
5. Valvular structures: The aortic valve is a normal structurewithout stenosis or regurgitation. The mitral valve is a normalstructure without stenosis or prolapse and there is a mild mitralregurgitation. The tricuspid valve is a normal structure withstenosis with trace to mild tricuspid regurgitation.
6. There is no pericardial effusion. No gross intracardiac mass orthrombus is appreciated; however, left atrial appendage is nevercompletely visualized.
7. Inferior vena cava collapsibility is normal, indicating normalright atrial pressure. Pulmonary artery pressure is normal.
CONCLUSION: Echocardiography reveals the patientto be back in atrial fibrillation with overall fairlywell-preserved right and left ventricular systolic function thoughleft ventricular function is somewhat difficult to assess and milddecrease in ejection fraction cannot be excluded. Diastolicfunction could not be assessed. There is only mild mitralregurgitation at this time. Right-sided pressures are normal. Hardcopy data are printed.
Jason Finkle, DO
what are the ICD- 10-CM codes and CPT codes?
that is exactly how the question is asked.
