Two Case Studies for someone familiar with 3MEncoder and (ICD-10-CM) (ICD10PCS)

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Two Case Studies for someone familiar with 3MEncoder and (ICD-10-CM) (ICD10PCS). Answer the questions in bold for both case studies. There are 9 questions in all.

Case 1

LOCATION: Inpatient, Hospital

PATIENT: Beverly Hill

ATTENDING PHYSICIAN: Gary Sanchez, MD

SURGEON: Gary Sanchez, MD

PATHOLOGIST: Grey Lonewolf, MD

CLINICAL HISTORY: Mass left atrium.

SPECIMEN RECEIVED: Myxoma—left atrium with FS.

GROSS DESCRIPTION: The specimen is labeled with the patient’s name and “left atrial myxoma,” and consists of a 4 × 2 × 2 cm ovoid mass with a partially calcified hemorrhagic white-tan tissue.

INTRAOPERATIVE FROZEN SECTION DIAGNOSIS: Myxoma, per Dr. Lonewolf.

MICROSCOPIC DIAGNOSIS: Sections show a well-circumscribed mass consisting of fibromyxoid tissue showing numerous vascular channels. Areas of superficial ulceration and chronic inflammatory infiltrate are noted. Areas of calcification are also present.

DIAGNOSIS: Myxoma, benign, left atrium.

Abstracting & Coding Questions:

1. The Specimen Received section indicates “FS.” What does FS stand for?

2. Is the intraoperative FS reported separately?

3. What CPT code(s) would be reported for this case?

4. What ICD-10-CM code(s) would be reported for this case?

Case 2

LOCATION: Inpatient, Hospital

PATIENT: Jo Littledove

REFERRING PHYSICIAN: James Noonar, MD

CARDIOLOGIST: Marvin Elhart, MD

INDICATIONS: Abnormal Cardiolite stress test and shortness of breath.

PROCEDURE: Right and left selective coronary angiogram, LV gram left heart, right femoral artery #6 French sheath, right femoral artery angiogram.

HEMODYNAMICS: Aortic pressure 138/57, LV 148/4. No aortic gradient on pullback.

RESULTS: Ventriculography: The LV displayed normal size with excellent contractility and no segmental wall motion abnormality. The ejection fraction is estimated at 60-80%.

Coronary Angiography

1. Right coronary artery: This is a dominant vessel. It has a shepherd’s crook takeoff. Through its course the right coronary artery has no significant stenosis. Distally, it trifurcated to give rise to posterior descending artery, posterolateral branch, and a marginal branch. Through its course the right coronary artery has intimal disease from 10-20%. 2. Left main: Normal. 3. Circumflex artery: The circumflex artery is a codominant system. The circumflex in its midportion branched to give first marginal that is moderate in size, tortuous, but no significant obstructive disease, and a very large second marginal that has in its midportion 40% stenosis. Distally, it branched to give smaller marginals. 4. Left anterior descending artery: After the takeoff of the left main, has steep angulations of close to 90 degrees. Thereafter it takes off and through its course has significant tortuosity. The proximal part of the left anterior descending appears slightly hazy, probably from the angulations; the artery itself has 30% stenosis. At the level of the stenosis there are two diagonals taking off, the first of which is before the stenosis and is small, and the second one is moderate in size and has at its origin an ostial stenosis that appeared to be 60%. The left anterior descending artery is tortuous and in its midportion gave rise to another diagonal that appeared to be free of any significant disease.

IMPRESSION/CONCLUSION: Normal left ventricular systolic functions with disease involving predominantly the left anterior descending artery that appeared to be in its proximal third of 40-50% at the level of the second diagonal. Angiographically, it did not appear severely obstructed, with some mild disease involving the right coronary artery at the circumflex. At this point, my recommendation is to aggressively manage her medically, and if we are unable to control her symptoms with medications, then later on

we might consider percutaneous revascularization of the left anterior descending artery. Considering her size, the location of the lesion, and the takeoff of the left anterior descending artery, this procedure is not without risk.

Abstracting & Coding Questions:

1. What does the LV referred to in the report stand for?

2. What is the definition of “circumflex”?

3. The report states in point 4 that the left anterior descending artery has significant tortuosity.What does this mean?

4. What CPT code(s) would be reported for this case?

5. What ICD-10-CM code(s) would be reported for this case?

Unformatted Attachment Preview

Case 1 LOCATION: Inpatient, Hospital PATIENT: Beverly Hill ATTENDING PHYSICIAN: Gary Sanchez, MD SURGEON: Gary Sanchez, MD PATHOLOGIST: Grey Lonewolf, MD CLINICAL HISTORY: Mass left atrium. SPECIMEN RECEIVED: Myxoma—left atrium with FS. GROSS DESCRIPTION: The specimen is labeled with the patient’s name and “left atrial myxoma,” and consists of a 4 × 2 × 2 cm ovoid mass with a partially calcified hemorrhagic white-tan tissue. INTRAOPERATIVE FROZEN SECTION DIAGNOSIS: Myxoma, per Dr. Lonewolf. MICROSCOPIC DIAGNOSIS: Sections show a well-circumscribed mass consisting of fibromyxoid tissue showing numerous vascular channels. Areas of superficial ulceration and chronic inflammatory infiltrate are noted. Areas of calcification are also present. DIAGNOSIS: Myxoma, benign, left atrium. Abstracting & Coding Questions: 1. The Specimen Received section indicates “FS.” What does FS stand for? 2. Is the intraoperative FS reported separately? 3. What CPT code(s) would be reported for this case? 4. What ICD-10-CM code(s) would be reported for this case? Case 2 LOCATION: Inpatient, Hospital PATIENT: Jo Littledove REFERRING PHYSICIAN: James Noonar, MD CARDIOLOGIST: Marvin Elhart, MD INDICATIONS: Abnormal Cardiolite stress test and shortness of breath. PROCEDURE: Right and left selective coronary angiogram, LV gram left heart, right femoral artery #6 French sheath, right femoral artery angiogram. HEMODYNAMICS: Aortic pressure 138/57, LV 148/4. No aortic gradient on pullback. RESULTS: Ventriculography: The LV displayed normal size with excellent contractility and no segmental wall motion abnormality. The ejection fraction is estimated at 60-80%. Coronary Angiography 1. Right coronary artery: This is a dominant vessel. It has a shepherd’s crook takeoff. Through its course the right coronary artery has no significant stenosis. Distally, it trifurcated to give rise to posterior descending artery, posterolateral branch, and a marginal branch. Through its course the right coronary artery has intimal disease from 10-20%. 2. Left main: Normal. 3. Circumflex artery: The circumflex artery is a codominant system. The circumflex in its midportion branched to give first marginal that is moderate in size, tortuous, but no significant obstructive disease, and a very large second marginal that has in its midportion 40% stenosis. Distally, it branched to give smaller marginals. 4. Left anterior descending artery: After the takeoff of the left main, has steep angulations of close to 90 degrees. Thereafter it takes off and through its course has significant tortuosity. The proximal part of the left anterior descending appears slightly hazy, probably from the angulations; the artery itself has 30% stenosis. At the level of the stenosis there are two diagonals taking off, the first of which is before the stenosis and is small, and the second one is moderate in size and has at its origin an ostial stenosis that appeared to be 60%. The left anterior descending artery is tortuous and in its midportion gave rise to another diagonal that appeared to be free of any significant disease. IMPRESSION/CONCLUSION: Normal left ventricular systolic functions with disease involving predominantly the left anterior descending artery that appeared to be in its proximal third of 40-50% at the level of the second diagonal. Angiographically, it did not appear severely obstructed, with some mild disease involving the right coronary artery at the circumflex. At this point, my recommendation is to aggressively manage her medically, and if we are unable to control her symptoms with medications, then later on we might consider percutaneous revascularization of the left anterior descending artery. Considering her size, the location of the lesion, and the takeoff of the left anterior descending artery, this procedure is not without risk. Abstracting & Coding Questions: 1. What does the LV referred to in the report stand for? 2. What is the definition of “circumflex”? 3. The report states in point 4 that the left anterior descending artery has significant tortuosity. What does this mean? 4. What CPT code(s) would be reported for this case? 5. What ICD-10-CM code(s) would be reported for this case? ...
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