Ask Dr. Z

Would the below support billing 93306? This was the whole report, and it seems to be very short, although it appears to hit the required elements. Should there be more depth of information documented?

Findings:

1) Technically diff apical imaging windows due to body habits

2) Rt ventricle 2.8cm

3) Lt atrium 4.2cm

4) Aortic root 2.8cm

5) Lt ventricular internal dimensions 3.9/2.6cm

6) Lt ventricular wall thickness 1.3/1.3cm

7) Lt ventricular systolic function is normal with a visually estimated EF of 60% & no definite regional wall motion abnormalities.

8) Aortic valve is suboptimally visualized. Some measure of aortic stenosis is probably present. The calculated aortic valve area was 1.6-1.8 cm2, which is not inconsistent with the 2-dimensional appearance of the valve.

9) No significant mitral valve dysfunction.

10) Peak tricuspid regurgitant jet velocity is 1.7 meters per second, suggestive of normal rt heart pressures.

11) There is a relatively echo free space anteriorly, which is consistent with a small pericardial effusion or epicardial fat.