Sample Perioperative Echo Report

1. Demographic and Other Identifying Information

Name_______________________ Unit #________________DOB_________ M/F Date________ Time____ Location: ICU/OR/ER/PACU, Phys requesting Echo __________________, Examiner________________ Indication_______________________ CPT Codes___________________ICD-9 codes_______________ Intubated: Y/N, Sedated: Y/N, Insertion: Easy/Difficult /Failed Probe Type: pediatric/ biplane/multiplane/ epicardial/epiaortic Modalities: 2D/CFM/PWD/CWD/Contrast/Pharm/Stress Tape/OD #__________

2.Echocardiographic and Doppler Measurements

Size

Aorta
Ascending Ao Ao Arch Descending Ao nl, dilated, aneur nl, dilated, aneur nl, dilated, aneur

Diam (cm)

Dissection y/n y/n y/n

Plaque thick (mm) 0-3, >3 0-3, >3 0-3, >3

Plaque mobile y/n y/n y/n

Annulus

Stenosis No, mild, Mod, severe No, mild, Mod, severe No, mild, Mod, severe

Valves
Aortic Valve Mitral Valve Tricuspid normal, dilated, calc, bioprosth, mechanical normal, dilated, calc, bioprosth, mechanical normal, dilated, calc, bioprosth, mechanical

Area/ Gradient

Regurg 0, 1+, 2+, 3+ 4+ 0, 1+, 2+, 3+ 4+ 0, 1+, 2+, 3+ 4+

Leaflet Morphology Nl, Calc, Veg, Perf, Bicuspid Thickened, Nl, Calc, Veg Perf, Myxom Thickened Nl, Calc, Veg Perf, Myxom Thickened

Leaflet Motion Nl, Prolapse Flail, Restricted NCC/RCC/LCC Nl, Prolapse, Flail, SAM, Restricted A1,A2,A3/ P1,P2,P3 Nl, Prolapse Flail, Restricted

Size

SEC (smoke)

Thrombus

Tumor

Device

Atria
Right atrium normal, dilated y/n y/n y/n y/n Left atrium normal, dilated y/n y/n y/n y/n Left atrial appendage: Interatrial Septum: Morphology: Normal, Aneurysm Lipomatous Hypertrophy, PFO, ASD (Primum, Secundum, Sinus Venosus, AV Canal) Shunt: (r->l, l->r, bidirectional) Interventricular Septum Morphology: Normal, Hypertrophy, Shift, Defect (membr, musc), Shunt: (r->l, l->r) Cavity size Cavity Dimension Hypertrophy y/n y/n Thrombu s y/n y/n Global FXN Nl, , , Nl, , , EF

Ventricles
RV LV normal, dilated normal, dilated

Regional Function: (1=normal, 2= hypokinetic, 3= akinetic, 4=dyskinetic) Basal Segments Anterior Anteroseptal Inferoseptal Inferior Mid Segments Anterior Anteroseptal Inferoseptal Inferior Apical Segments Anterior Septal Inferior ateral Inferolateral Inferolateral True apex Anterolateral Anterolateral Pericardium: Normal, Thickened, Effusion: mild, moderate, severe, Tamponade Pleura: nl,effusion

Post Intervention Follow-up Study: See additional report, No Change, Ventricular Fxn:
Global FXN: Improved, Decreased, Regional FXN: Improved, Decreased, Valve FXN: Native Valve: no change, improved, Normal Prosthetic Valve type_________ nl fxn?: Y/N, Valve repair: 0 leak, 1+,2+,3+, Valve area___

3.Comments:________________________________________________________________________
______________________________________________________________________________________ 4.Summary:_________________________________________________________________________ ____________________________________________________________________________________

5.Complications: None,details:_________________________________________________________

Appendix One: CPT Codes and Modifiers

93312 - TEE, 2D Imaging (w or w/o M-mode); including probe placement, image acquisition, interpretation and report. 93315 - TEE for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report. 93318 - TEE Echocardiography, transesophageal (TEE) for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate time basis. 93314 93316 93317 List separately in addition to codes for echocardiographic imaging: 93320 93321 93325 93350 PWD and/or CWD; complete PWD and/or CWD; f/u or limited study Color flow velocity mapping Stress echocardiography with interpretation and report (list appropriate stress testing code in addition, 93015-92018)

Modifiers 26 Professional/physician component of a service: Indicates interpretation of diagnostic tests 59 Distinct procedural service: Indicates that a procedure or service was distinct or independent from other services performed on the same day. Report it with two procedures that are not usually reported together to show that they are both necessary under the circumstances. Use in place of the GB modifier under the National Correct Coding Policy.

Appendix Two: Sample ICD-9 Codes for 93312

Valvular Assessment (Prosthesis) 996.02 Mechanical complication of heart valve prosthesis 996.71 Complications of internal device - graft NEC due to heart valve prosthesis V43.3 Heart valve replacement, NEC Aorta Assessment (Cannulation) 440.0 Atherosclerosis of aorta Aorta Assessment (Trauma) 441.01 Dissection of aorta, thoracic 441.03 Dissection of aorta, thoracoabdominal 441.1 Thoracic aneurysm, ruptured 441.2 Thoracic aneurysm, without mention of rupture 441.6 Thoracoabdominal aneurysm, ruptured 441.7 Thoracoabdominal aneurysm, without mention of rupture 444.1 Thoracic aortic embolism 901.0 Injury to Aorta Hypotension 38.9 276.5 458.8 458.9 429.4 785.50 785.51 958.4 998.0 998.51 998.59 Septicemia Volume depletion Hypotension, specified Hypotension, unspecified Functional disturbances following cardiac surgery Shock, unspecified Cardiogenic Shock Traumatic Shock Postoperative shock Infected postoperative seroma Other postoperative infection

Heart Transplant V42.1 V42.6 Tumor 164.1 198.89 Malignant neoplasm of heart Secondary malignant neoplasm, NEC Heart transplant status Lung transplant status

212.7 238.8 239.8

Benign neoplasm of heart Neoplasm of uncertain behavior, NEC (heart, eye) Neoplasms of unspecified nature, site NEC

Other Diagnoses 414.11Coronary vessel aneurysm 415.0 Acute cor pulmonale 415.11Iatrogenic pulmonary embolism and infarction 415.19 Other pulmonary embolism and infarction 417.0 Arteriovenous fistula of pulmonary vessels 417.1 Aneurysm of pulmonary artery 424.91 Endocarditis in diseases classified elsewhere 427.31 Atrial fibrillation 427.32 Atrial flutter 793.2 Widened mediastinum on radiological exam of thorax 861.00 - 861.03 Injury to heart, without mention of open wound into thorax 861.10 - 861.13 Injury to heart, with open wound into thorax 996.01 Mechanical complication of cardiac pacemaker (electrode) 996.61 Infection and inflammatory reaction due to cardiac device, implant and graft 996.72 Complications of internal device - graft NEC due to other cardiac device - implant graft 999.1 Air embolism Ventricular Assessment 441.10 414.19 422.91 422.92 425.1 429.71 458.9 459.2 745.4 785.50 785.51 785.59 958.4 999.1 V15.1 Aneurysm, heart - wall Aneurysm of heart, NEC Idiopathic myocarditis Septic myocarditis Hypertrophic obstructive cardiomyopathy Acquired cardiac septal defect Hypotension, unspecified Compression of vein Ventricular septal defect Shock, unspecified Cardiogenic Shock Shock without mention of trauma, NEC Traumatic shock Air embolism - complications of medical care, NEC Personal history of surgery to heart and great vessels

VOLUME ASSESSMENT 276.5 276.6 Hypovolemia Fluid overload

VALVULAR ASSESSMENT (NATIVE) 391.1 Acute rheumatic endocarditis 394.0 Mitral stenosis 394.1 Rheumatic mitral insufficiency 394.2 Mitral stenosis with insufficiency 395.0 Rheumatic aortic stenosis 395.1 Rheumatic aortic insufficiency 395.2 Rheumatic aortic stenosis with insufficiency 396.0 Mitral valve stenosis and aortic valve stenosis 396.1 Mitral valve stenosis and aortic valve insufficiency 396.2 Mitral valve insufficiency and aortic valve stenosis 396.3 Mitral valve insufficiency and aortic valve insufficiency 396.8 Multiple involvement of mitral and aortic valves 397.0 Diseases of tricuspid valve 397.1 Rheumatic diseases of pulmonary valve 421.0 Acute and subacute bacterial endocarditis 424.0 Mitral valve disorders 424.1 Aortic valve disorders 424.2 Nonrheumatic tricuspid valve disorders 424.3 Pulmonary valve disorders 425.4 Other cardiomyopathy 425.5 Alcoholic cardiomegaly 429.3 Cardiomegaly 429.5 Rupture of chordae tendineae 429.6 Rupture of papillary muscle 429.81 Papillary muscle disease, NEC 746.3 Congenital stenosis of the aortic valve 746.4 Congenital insufficiency of the aortic valve

Congenital 745.5 745.61 745.9 747.0 747.42 Ostium Secundum ASD or PFO Ostium Primum defect Unspecified ASD PDA Partial anomalous pulmonary venous drainage