CLINICAL SUMMARY: The patient is a 55-year-old female with known coronary disease and previous left anterior descending and diagonal artery intervention, with recent recurrent chest pain. Cardiac catheterization demonstrated continued patency of the stented segment, but diffuse borderline changes in the ostial/proximal portion of the right coronary artery.PROCEDURE: With informed consent obtained, the patient was prepped and draped in the usual sterile fashion. With the right groin area infiltrated with 2percent Xylocaine and the patient given 2 mg of Versed and 50 mcg of fentanyl intravenously for conscious sedation and pain control, the 6 French catheter sheath from the diagnostic study was exchanged for a 6 French sheath and a 6 French JR4 catheter with side holes utilized. The patient initially received 3000 units of IV heparin, and then IVUS interrogation was carried out using an Atlantis Boston Scientific probe. After it had been determined that there was significant stenosis in the ostial/proximal segment of the right coronary artery, the patient received an additional 3000 units of IV heparin, as well as Integrilin per double bolus injection. A 3.0 16-mm-long Taxus stent was then deployed in the ostium and proximal segment of the right coronary artery in a primary stenting procedure with inflation pressure up to 12 atmospheres applied. Final angiographic documentation was carried out, and then the guiding catheter pulled, the sheath upgraded to a 7 French system, because of some diffuse oozing around the 6 French sized sheath, and the patient is now being transferred to telemetry for post-coronary intervention observation and care.RESULTS: The initial guiding picture of the right coronary artery demonstrates the right coronary artery to be dominant in distribution, with luminal irregularities in its proximal and mid-third with up to 50 percent stenosis in the ostial/proximal segment per angiographic criteria although some additional increased radiolucency observed in that segment.IVUS interrogation confirms severe, concentric plaque formation in this ostial/proximal portion of the right coronary artery with over 80 percent area stenosis demonstrated. The mid, distal lesions are not significant, with less than 40 percent stenosis per IVUS evaluation.Following the coronary intervention with stent placement, there is marked increase in the ostial/proximal right coronary artery size, with no evidence for intimal disruption, no intraluminal filling defect, and TIMI III flow preserved.CONCLUSION: Successful coronary intervention with drug eluting Taxus stent placement to the ostial/proximal right coronary artery. What CPT® coding is reported?

A covered entity does NOT include

What is the ICD-10-CM coding for personal history of colonic polyps?

A 14-year-old status post injury over one year ago to her left wrist presented with recurrent wrist pain. The patient was taken to the operating room and placed under general anesthesia. She was placed in wrist traction. The radiocarpal joint was entered endoscopically through sharp skin incisions and blunt dissection into the joint. There was found to be mild synovitis in the dorsal ulnar aspect of the wrist. This was debrided arthroscopically with a shaver. There was a peripheral tear of the triangular fibrocartilage. This area was shaved to promote healing. Using outside-in technique, a PDS suture was placed across the TFCC and into the capsule. There was synovitis within the midcarpal joint, but there was no articular injury. All instruments were removed and the wounds were closed with interrupted nylon sutures. What CPT® code(s) is /are reported?

A 26-year-old patient presents with headache, neck pain and fever and is concerned he may have meningitis. The patient was placed in the sitting position and given 0.5 mg Ativan IV. His back was prepped and a 20-gauge needle punctured the spine between L4 and L5 with the return of clear fluid. The cerebrospinal fluid was reviewed and showed no sign of meningitis. What CPT® code is reported?

A patient is prescribed anticonvulsant medication for her seizures. She returns to her doctor three days later with nausea and rash from taking the anticonvulsant medication. The provider notes that this is a drug reaction to an anticonvulsant and changes the medication. What ICD-10-CM codes are reported?

A patient with type 2 diabetes presents with diabetic macular edema and proliferative diabetic retinopathy in the right eye. What ICD-10-CM code(s) is/are reported?

A provider has ordered de-ironing by therapeutic phlebotomy to be performed weekly. The patient is diagnosed with hemochromatosis and therapeutic phlebotomy is used to avoid irreversible tissue damage. One unit of blood is removed weekly. What CPT® and ICD-10-CM codes are reported for each weekly visit treatment?

A patient is positioned on the scanning table headfirst with arms at the side for an MRI of the thoracic spine and spinal canal. A contrast agent is used to improve the quality of the images. The scan confirms the size and depth of a previously biopsied leiomyosarcoma metastasized to the thoracic spinal cord. What CPT® and ICD-10-CM codes are reported?

The mediastinum contains all of the following except: