Procedure: Right femoral angiography, percutaneous transluminal tibioperoneal angioplasty and stenting. Description of Procedure: The patient was premedicated and brought to the cardiovascular laboratory. The right inguinal region is prepped and draped in the usual sterile fashion. Local cutaneous anesthesia was obtained with 1% Lidocaine. A 6 French sheath was inserted antegrade into the right femoral artery. It was kinked and was replaced with a 6 French Arrow sheath.Findings: Selective injections into the right femoral artery revealed diffuse irregularities of the superficial femoral artery with a 95 percent mid to distal stenosis and a 60 percent distal stenosis. The distal popliteal artery had an eccentric 60 percent stenosis. The tibial peroneal trunk was diffusely diseased with sequential 95 percent stenosis present. The anterior tibial and posterior tibial arteries are both occluded. We gave intravenous heparin 2,500 units. The distal vessel was wired with a V18 wire. We then dilated both superficial femoral artery lesions with a 5 x 4 Diamond balloon and achieved good angiographic result. We then elected to approach the tibial peroneal trunk that was a high-grade stenosis leading into the only remaining circulation. This was dilated with a 3 x 4 Diamond balloon. This had satisfactory results, but we elected to stent this for a better long-term patency. We exchanged out the V18 wire for a coronary extra support wire and deployed a 3.5 x 40 mm GR2 coronary stent. This was then post-dilated to high pressures with a 3.5 x 40 mm NC Bandit balloon. We then performed inflations in the popliteal artery with a 4 x 2 Symmetry balloon, also achieving a satisfactory angiographic result. The balloon catheter was then withdrawn. The final angiographic result was excellent, with wide patency from the superficial femoral artery into the peroneal down to the ankle. Following the procedure, an ACT was obtained. The sheath was removed. A strong popliteal pulse was obtained. The patient was transported in stable condition to the recovery unit.Impression:      1. Successful percutaneous transluminal angioplasty of sequential 95 and 60 percent mid and distal superficial femoral artery lesions.      2. Successful percutaneous transluminal angioplasty of a 60 percent popliteal lesion.      3. Successful percutaneous transluminal angioplasty of diffuse 95 percent tibial peroneal trunk stenosis with stenting producing a residual stenosis to 0 percent. Which angioplasty codes are correct to report?

A patient with sickle cell anemia with painful sickle crisis received normal saline IV 100 cc per hour to run over 5 hours for hydration in the provider’s office. She will be given Morphine & Phenergan, prn (as needed). What codes are reported?

The patient is here because the cyst in her chest has come to a head and is still painful even though she has been on antibiotics for a week.  I offered to drain it for her. After obtaining consent, we infiltrated the area with 1 cc of 1% lidocaine with epinephrine, prepped the area with Betadine and incised and opened the cyst in the relaxed skin tension lines of her chest, and removed the cystic material. There was no obvious purulence. We are going to have her clean this with a Q-tip. We will let it heal on its own and eventually excise it. I will have her come back a week from Tuesday to reschedule surgery. What CPT® and ICD-10-CM codes are reported?

What is an example of an eponym?

Dr. Smith is treating a 72-year-old female with ureteral obstruction caused by a postoperative stricture and post radiation scarring following treatment for transitional cell cancer. The patient requires removal and replacement of an internal indwelling ureteral stent. Dr. Smith advances a diagnostic catheter under conscious sedation into the bladder and injects contrast to opacity the bladder. A guide wire is advanced into the bladder and the diagnostic catheter is exchanged for a larger catheter to allow the use of a snare device. Under the fluoroscopic guidance the snare device is negotiated into the bladder through the sheath and used to grasp the pigtail portion of the double-J ureteral stent tube within the bladder and the indwelling stent tube is pulled out of the bladder and urethra far enough to allow retrograde introduction of a guide wire through the stent, directed into the renal pelvis. Using fluoroscopic guidance to negotiate the wire through the inner lumen of the ureteral stent tube rather than through side holes, a diagnostic catheter is positioned over the wire into the renal pelvis, allowing opacification and visualization of the renal pelvis. The guide wire is repositioned into the renal pelvis and the diagnostic catheter removed. A new double-J ureteral stent tube is introduced and positioned. The guide, sheath and safety wire are removed after appropriate position is confirmed with fluoroscopy and a permanent image is obtained for the medical record. What code is used to describe the exchange?

A 40-year-old female is scheduled for a routine screening baseline bilateral mammogram with computer-aided detection (CAD). What are the CPT® and ICD-10-CM codes reported?

The provider saw an established patient in his office and decided to admit an 18-month-old infant to the hospital from his office to rule out sepsis. The infant is crying inconsolably. He has a large amount of gas in his bowel, no hematochezia associated with it. The provider documented two distinct notes and saw the patient in the office and in the hospital. A medically appropriate history and exam were documented in both settings. In the hospital, the provider ordered a CBC, EKG and chest x-ray and started the patient on antibiotics. If cultures are negative and the patient remains afebrile for 48 hours, the infant will be discharged home. According to the CPT® E/M guidelines, what CPT® code is reported for this visit?

Tomographic axial images (CT or CAT scan) through the abdomen were obtained without administration of intravenous contrast. This showed a 3 cm diameter mass in the upper pole of the right kidney abutting the liver. Cryoablation of the lesion was performed utilizing two freezing cycles with good cosmetic results. What CPT® codes are reported?

An elderly male patient presents to the ED complaining of a high fever the day prior to the encounter and of extreme lethargy. He has a history of benign hypertension which has been elevated. On arrival he was examined by his primary care physician and admitted, with possible urinary tract infection and concern for his elevated blood pressure. He was noted to have hematuria and a urine culture is performed. Positive UTI and pseudomonas showed in the urine culture and IV antibiotics were administered. During the course of the day, his fever decreased, and his lethargy improved.  As the IV fluids were decreased, he resumed a benign hypertensive state. On the next hospital day, his primary care physician noted the urine was clear and he was discharged on oral antibiotics. What ICD-10-CM codes should be reported?

The physician is on the hospital floor for the medical management of a 56-year-old patient who he admitted one day ago with chest pain due to aspiration pneumonia. Patient indicates no chest pain at present, but still SOB and some swelling in his lower extremities. Patient was tachypneic yesterday; examination of the lungs reveals course crackles in both bases, right worse than left. The physician writes instructions to continue with intravenous antibiotic treatment and respiratory support with ventilator management. He reviewed chest X-ray and labs that were ordered yesterday. Patient is improving and a pulmonary consultation has been requested. What CPT® code is reported?