AAPC - Chapter 20 Practical Applications
CASE 2 Pre-procedure Diagnosis: Asthma Post-procedure Diagnosis: Asthma (Post procedural diagnosis used for coding.) Procedure: Psychophysiological Therapy Biofeedback The patient returned to clinic with daily diary documenting home peak flow readings and asthma symptoms. Diary was assessed and discussed with patient. Patient reports reduced dosing with inhaled steroids and fewer asthmatic episodes. Lungs and respiratory resistance assessed. Lungs clear, no wheezes or rhonci noted. (Psychophysiological training.) HRV biofeedback was performed using a physiograph. (Biofeedback documentation.) ECG data were collected from the left arm and right leg, and were digitized at 510 Hz. EEG biofeedback equipment attached and baroreflex gain was assessed with beat-to-beat BP recordings and digitized at a rate of 252 samples per second. The sensor was placed on the participant's right middle finger, and the hand was elevated on a table to approximately the level of the heart. Respiratory system impedance (Zrs) (between 2 and 32 Hz with 2-Hz increments) was measured using a pseudorandom noise forced oscillation system. It was presented in 40 2-second bursts spaced equally throughout In order to minimize the effects of possible partial glottal closure during exhalation, each burst was triggered by the beginning of an inhalation. Post procedure, Inspirometer readings were recorded. Asthma symptoms were scored with the patient. Biofeedback procedure lasted approximately 28 minutes. (Biofeedback time.) The patient is to return to clinic in two weeks with daily diary. It is expected the patient will continue with reduced regiment and asthmatic episodes. What are the CPT® and ICD-10-CM codes reported?
90875 J45.909
CASE 3 Performed in the office Pre-procedure Diagnosis: Gastro-esophageal reflux disease (GERD), Heartburn Post-procedure Diagnosis: GERD (Post procedure diagnosis used for coding.) Procedure: Esophageal pH monitoring with Bravo pH Capsule (Acid reflux testing) Patient was placed in supine position on examining bed, IV moderate sedation was administered. Visualization of esophagus with anatomic markers located during endoscopy. Endoscopy was removed and the Bravo pH Capsule delivery system was passed into the esophagus using the oral passage until the attachment site was obtained at approximately 5cm proximal to the upper margin of the LES. The external vacuum pump was activated pulling the adjacent esophageal mucosa into the fastening well. Vacuum gauge at 600 mm Hg and held for 10 seconds. The plastic safety guard on handle was then removed and the activation button was depressed and turned attaching the pH capsule to the esophageal wall. (Placement of electrode placement.) The activation button on handle was then twisted 90 degrees and re-extended, releasing the pH capsule. Esophagoscopy was repeated to verify capsule attachment. Prior to procedure, the Bravo pH capsule was activated and calibrated by submersion in pH buffer solutions. The patient tolerated the procedure well and was transferred into the recovery room. The patient returned to the office two days later for download of the recording. The information was analyzed and interpreted. What are the CPT and ICD-10-CM codes reported?
91035 K21.9
CASE 5 Pre-procedure Diagnosis: Aortic insufficiency; hypertension Post-procedure Diagnosis: Borderline Left Ventricular Hypertrophy, Mild Aortic Insufficiency, (Post-procedure diagnosis used for coding.) Left ventricular Ejection Fraction 80% (Indicates severity.) Procedure: 2D with M-mode Echocardiogram (2D echo, M-Mode.) with pulsed continuous wave with spectral display (Spectral Doppler.) and Doppler color flow mapping (Doppler Color Flow.) Patient positioned in supine position on exam table. Echocardiogram proceeded without incidence. Findings: Borderline left ventricular hypertrophy. Mild aortic insufficiency. Left ventricular ejection fraction 80%. What are the CPT® and ICD-10-CM codes reported?
93306 I51.7 I35.1
CASE 6 Pre-procedure Diagnosis: Persistent Right and Left Leg pains; Extensive varicose vein disease Post-procedure Diagnosis: Varicose vein disease with inflammation, venous insufficiency, leg pains due to varicose veins Procedure: Peripheral Vascular Duplex Ultrasound Evaluation of the Venous Anatomy of the Lower Extremities Patient's right and left leg venous anatomy was examined in the standing position utilizing a B-Mode Duplex ultrasound machine with a 12 MHz probe. The focus was to determine the location and flow characteristics of both the deep and superficial venous systems. The evaluations included dynamically focused gray-scale and color imaging supplemented by Doppler spectroanalysis. Valsalva maneuver as well as calf and thigh compressions were performed to determine the patency and direction of blood flow, the exact paths of venous reflux in the major venous trunks, tributaries, and perforator veins. Ultrasonic mapping included images of major deep veins of the leg, saphenofemoral junction, the great saphenous vein above and below the knee, and the short saphenous vein system below the knee. Measurements and flow characteristics were obtained and listed on venous map in chart. Bilaterally, the great saphenous veins were absent beginning at the saphenofemoral junction, due to previous surgery. Noted was venous reflux and enlargement of neovascular and tributary portions of the vein systems in the upper and lower legs. Abnormalities and associated perforator veins were documented on venous map in chart. The internal diameters of the leg varicosities varied to 5 and 3.8mm in diameter, bilaterally. No evidence of deep venous reflux or thrombosis noted within the femoral, popliteal, gastroncnemius, or posterior tibial vessels. Photocopies were taken of the venous abnormalities and are included in the medical record. Findings: Varicose vein disease with inflammation Venous insufficiency Leg pains due to varicose veins What are the CPT and ICD-10-CM codes?
93970 I83.11 I83.12 I83.813
CASE 10 Pre-procedure Diagnosis: Palpable Pulsating Abdominal Mass Post-procedure Diagnosis: AAA Procedure: Abdominal Aorta Duplex Ultrasound by ultrasound technician The patient was placed on the examining table in a supine position. Conductive gel was applied to the abdomen. The transducer was gently moved over the abdomen. An aortic mass was identified within the inferior aorta at approximately the 3.2 cm mark. Measurements were marked and recorded. Anterior-posterior measurement equaled 4.8 cm and transverse measurement equaled 5.7 cm. Report views and results were given to the ER physician caring for the patient by the radiologist who interpreted the ultrasound. What are the CPT® and ICD-10-CM codes reported?
93979-26 I71.4
CASE 4 Pre-procedure Diagnosis: Sleep Apnea Post-procedure Diagnosis: Obstructive sleep apnea Procedure: Overnight Sleep Study 35-year-old patient in Hospital Sleep Lab for attended, overnight polysomnogram. (Polysomnogram performed.) Patient oriented to room and changed into overnight clothing and brought into lab by patient. Latency to sleep onset slightly prolonged at 32.3 minutes. During the first 82 minutes of sleep, 80 obstructive apneas were manifested (Respiratory Effort). The lowest SpO2 during the non-supplemented sleep period was 73% (Oxyhemoglobulin saturations (SPO2)). CPAP was then applied at 5 cm H2, and sequentially titrated to a final pressure of 18 cm H2O. The Apnea-hypopnea index (AHI) changed from 60 events/hr to 4 events/hr. SpO2 increased to 90%. The sleep study with and without CPAP shows severe obstructive sleep apnea with improvement with CPAP settings at 18 cm H20. Based on the improved SpO2 levels with CPAP, it is recommended this patient use a BIPAP machine during sleep hours due to obstructive sleep apnea events. What are the CPT® and ICD-10-CM codes reported?
95808 G47.33
CASE 7 Pre-procedure Diagnosis: Excessive Daytime Sleepiness, Snoring, Epworth Score 18 Post-procedure Diagnosis: Sleep Study Procedure: Polysomnogram, attended 25 year-old patient underwent overnight polysomnogram with the recording of EEG, EOG, submental and anterior tibialis EMG, respiratory effort, nasal and oral airflow, EKG, continuous pulse oximetry. Total time in bed of 386 minutes and a total of sleep time of 221 minutes. The sleep latency was 24 minutes and the REM sleep latency was 18 minutes. Throughout the night, the patient had a total of 256 episodes of arousals and 6 awakenings. Sleep efficiency was 56%. No apparent parasomnia noted. The average oxygen saturation was reported to be 95% with the lowest saturation being 84%. There were no periodic leg movements for an index of 0.0 and cardiac arrhythmias were not present. Impression: Mild sleep apnea What are the CPT® and ICD-10-CM codes reported?
95810 G47.30
CASE 8 Pre-procedure Diagnosis: Analysis of Vagal Nerve Stimulator (VNS), epilepsy with history of seizures Post-procedure Diagnosis: Analysis of Vagal Nerve Stimulator (VNS), epilepsy with history of seizures Procedure: Vagal Nerve Stimulator Analysis Patient here for VNS implant analysis with possible adjustments. The programming head was placed over the implanted neurostimulator located within the patient's neck-left side. Impedance was verified insuring parameters within normal limits. Parameters charted on flowchart within medical record. Operating status of neurostimulator reflects on. Estimated time for analysis/interrogation was 20 minutes in duration. Patient denies questions at this time. Will repeat analysis in three months. What are the CPT® and ICD-10-CM codes reported?
95970 G40.909 Z96.89
CASE 9 Pre-procedure Diagnosis: Extensive keratosis lesions of left anterior neck Post-procedure Diagnosis: keratosis lesions left anterior neck Procedure: Blue Light Photodynamic Therapy with topical skin sensitizing agent Patient here for photodynamic therapy. Verbal instruction of procedure given to patient with patient verbalizing understanding. Patient positioned self in supine position on exam table. Safety goggles applied to eyes, noting patent seal and full coverage of ocular orbital areas. Application of topical Levulan® Kerastick® applied to left anterior neck keratosis lesions. Blue light lamp adjusted to reflect on left anterior neck. Phototherapy duration: 15 minutes. Post procedure skin was slightly reddened, no swelling noted. Post-procedure instructions were discussed with patient. Patient to return to office in eight weeks for assessment and possible repeat treatment. Procedure performed by the physician. What are the CPT® and ICD-10-CM codes reported?
96573 J7308 L57.0
CASE 1 10-Year-old established patient (The patient is established.) presents today for well child check (Patient presents for a preventive exam.) with mother with complaints of frequent urination during the day. The patient has two sisters and sees dad sporadically. Lives in a smoke free environment. One dog, one rabbit. Denies dysuria, abdominal pain, or rashes, all other systems are reviewed and negative. Patient going into 4th grade with good grades. No parental concerns. Patient cooperates but does tend to back talk. Doing well on Concerta Exam General: Normal Head: Normal Eyes: Normal Ears: Normal Nose: Normal Mouth/throat: Normal Neck: Normal Abdomen: Normal Rectal: Not examined Genitals: Normal Skin: 3mm papule on dorsal R hand without disruption of creases Urinalysis: Ketones, nitrite, leukocytes normal; trace blood, low specific gravity. (Urinalysis lab test performed in the office) Counseled patient on the use of seat belts, bicycle/skate helmets, gun safety, water/sun safety. Assessment: Well Child Check, ADHD, Wart, Frequent Urination (Preventive exam and problems treated.) Refill Concerta 18mg PO q AM Wart cleansed with alcohol. Histofreeze x 25 seconds (Wart is destroyed.) was performed to destroy the wart. Varicella Vaccine #2 (Vaccination is administered.) administered without any complications. What are the CPT® and ICD-10-CM Codes?
99393-25 17110 90471 90716 81002 Z00.121 F90.9 B07.9 R35.0 Z23