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* 編碼討論平台-已結案
* 2020-11-16
診斷/手術名稱 出院診斷: Coronary artery disease, triple vessel s/p coronary artery bypass graft X II (LIMA-LAD, GSV-OM) on 2020/07, s/p CAG with occluded graft vessels, s/p DCB over LCx-P and PTCA+DES over LAD-P on 2020/11/6
病歷相關內容(診斷/手術)描述 手術及處置:
s/p CAG with occluded graft vessels, s/p DCB over LCx-P (2.5X25 B.Braun Sequent Please NEO Balloon ) and PTCA+DES over LAD-P(3.5X18mm Xience Sierra Stent) on 2020/11/6

心導管:

Indication:
Tl-201 scan positive
Events :
2020/11/06 12:15 : Heparin 7500 u

Finding:
LM:
-70% stenosis
LAD:
-P: calcification with 80% stenosis
LCx:
-P: diffuse lesion with stenosis over 90%
RCA:
-s/p previous stenting, without significant ISR
LIMA to LAD
-occluded
GSV to OM
-occluded

Intervention:
13. Distal circumflex()
1.3.5X6F EBU Guide catheter
2.Fielder FC 0.014" 180cm Guidewire
3.6.0FrX_ Guidezilla Microcatheter
4.Fielder XT A 0.014" 190cm Guidewire
5.2.5X25 B.Braun Sequent Please NEO Balloon _ atm. _ times _

7. LAD mid()
1.3.5X6F EBU Guide catheter
2.Fielder FC 0.014" 180cm Guidewire
3.6.0FrX_ Guidezilla Microcatheter
4.3.5X18mm Xience Sierra Stent _ atm. _ times _


Diagnosis:
CAD, TVD, s/p previous stenting over LAD-M and RCA-P to -M, s/p
CABG x II (LIMA-LAD, GSV-OM); in stable angina, s/p CAG with
occluded graft vessels, s/p DCB over LCx-P (2.5X25 B.Braun
Sequent Please NEO Balloon ) and PTCA+DES over LAD-P (3.5X18mm
Xience Sierra Stent) on 2020/11/6



編碼問題說明 請問:
s/p CAG with occluded graft vessels, s/p DCB over LCx-P and PTCA+DES over LAD-P
ICD 10 CM 編碼 應編在 I25.810 ? 或是應該編在 T82.858 ?,
I25.810 VS. T82.858 這2個編碼應該如何辨別?
最後結論 依工具書查找
Complication (s) (from) (of)
coronary artery graft (bypass) T82.9
atherosclerosis --see Arteriosclerosis, coronary (artery),
stenosis T82.858
編碼至T82.858-,如病歷有提及動脈粥狀硬化(atherosclerosis),則可編至I25.810。