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Author Archives: Anonymous

After intravenous administration of 5.1 millicuries Tc-99m D…

After intravenous administration of 5.1 millicuries Tc-99m DTPA, flow imaging of the kidneys was performed for approximately 30 minutes. Flow imaging demonstrated markedly reduced flow to the kidneys bilaterally. What CPT® code is reported?

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CLINICAL SUMMARY: The patient is a 41-year-old female with k…

CLINICAL SUMMARY: The patient is a 41-year-old female with known coronary disease and recent recurrent chest pain, cardiac catheterization demonstrated subtotal occlusion of the diagonal artery at its takeoff from the left anterior descending artery.PROCEDURE: With informed consent obtained, the patient was prepped and draped in the usual sterile fashion. With the right groin area infiltrated with 2% Xylocaine, the patient was given 2 mg of Versed and 50 mcg Fentanyl intravenously for conscious sedation and pain control. The right femoral artery was cannulated with a modified Seldinger technique and a 6 French catheter sheath placed. A 6 French JL3.5 catheter with no side holes was utilized as a guiding catheter. After the initial guiding picture had been obtained, the patient was given Angiomax per protocol, and a short Cross-it 100 wire was advanced to the LAD and then into the diagonal vessel. A 2.0. 15-mm-long Maverick balloon was used for dilatation of the diagonal artery ostium with inflation pressure up to 8 atmospheres applied. Final angiographic documentation was carried out after the patient received 200 mcg of intracoronary nitroglycerine. The guiding catheter was then pulled, the sheath secured in place. The patient is now being transferred to telemetry for post coronary intervention observation and care.RESULTS: The initial guiding picture of the left coronary system demonstrates the high-grade ostial stenosis of the diagonal artery taking off within the LAD. Following the coronary intervention with balloon angioplasty there is complete resolution of the stenosis with less than 10 percent residual narrowing observed, no evidence for intimal disruption, no intraluminal filling defect, and good antegrade TIMI III flow preserved.CONCLUSION: Successful coronary intervention with balloon angioplasty to the ostial/proximal segment of the second diagonal vessel. What CPT® code is reported?

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A 23-year-old woman presents with sudden LLQ (left lower qua…

A 23-year-old woman presents with sudden LLQ (left lower quadrant) pain which does not resolve. The decision is made to perform exploratory laparoscopy revealing a cyst on the left ovary. The cyst is removed along with a partial oophorectomy. What is/are the CPT® code(s) reported for this procedure?

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What type of CPT® code is “modifier 51 exempt” even though t…

What type of CPT® code is “modifier 51 exempt” even though there is no modifier 51 exempt symbol next to it?

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Ultrasound indicates a 20-week fetus has a distended bladder…

Ultrasound indicates a 20-week fetus has a distended bladder and the decision is made to perform vesicocentesis. The procedure is successful and the bladder is emptied. What CPT® is code reported for this procedure?

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The patient is here to see us about some skin tags on her ne…

The patient is here to see us about some skin tags on her neck and both underarms. She has had these lesions for some time; they are irritated by her clothing, itch, and at times have a burning sensation. We discussed treatment options along with risks. Informed consent was obtained and we proceeded. We removed 16 skin tags from the right axilla, 16 skin tags from the left axilla, 10 from the right side of the neck and 17 from the left side of the neck. What CPT® and ICD-10-CM codes are reported?

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A 23-year-old patient presents to the emergency department (…

A 23-year-old patient presents to the emergency department (ED) with a cut on his leg. He is a confirmed AIDS patient as documented in the record. What ICD-10-CM codes should be reported?

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What do the services in the Reproductive Medicine Procedures…

What do the services in the Reproductive Medicine Procedures section of the Pathology and Laboratory chapter of CPT® report?

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Which statement is true regarding coding of carbuncles and f…

Which statement is true regarding coding of carbuncles and furuncles in ICD-10-CM?

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A patient undergoes heart surgery for angina decubitus and c…

A patient undergoes heart surgery for angina decubitus and coronary artery disease (CAD). What ICD-10-CM coding is reported?

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