View MR 099405
MR 099405
CC: Shortness of breath
HPI: 16-year-old female comes into the ED for shortness of breath for the last two days. She is an asthmatic.
Current medications being used to treat symptoms is Advair, which is not working and breathing is getting worse. Does not feel that Advair has been helping. Patient tried Albuterol for persistent coughing, is not helping. Coughing 10-15 minutes at a time. Patient has used the Albuterol 3x in the last 16 hrs. ED physician admits her to observation status.
ROS: No fever, no headache. No purulent discharge from the eyes. No earache. No nasal discharge or sore throat. No swollen glands in the neck. No palpitations. Dyspnea and cough. Some chest pain. No nausea or vomiting. No abdominal pain, diarrhea, or constipation.
PMH: Asthma
SH: Lives with both parents.
FH: Family hx of asthma, paternal side
ALLERGIES: PCN-200 CAPS. Allergies have been reviewed with child's family and no changes reported.
PE: General appearance: normal, alert. Talks in sentences. Pink lips and cheeks. Oriented. Well developed. Well nourished. Well hydrated.
Eyes: normal. External eye: no hyperemia of the conjunctiv
a. No discharge from the conjunctiva
Ears: general/bilateral. TM: normal. Nose: rhinorrhea. Pharynx/Oropharynx: normal. Neck: normal.
Lymph nodes: normal.
Lungs: before Albuterol neb, mode air entry b/l. No rales, rhonchi or wheezes. After Albuterol neb. improvement of air entry b/l. Respiratory movements were normal. No intercostals inspiratory retraction was observed.
Cardiovascular system: normal. Heart rate and rhythm normal. Heart sounds normal. No murmurs were heard.
GI: abdomen normal with no tenderness or masses. Normal bowel sounds. No hepatosplenomegaly
Skin: normal warm and dry. Pink well perfused
Musculoskeletal system patient indicates lower to mid back pain when she lies down on her back and when she rolls over. No CVA tenderness.
Assessment: Asthma, acute exacerbation
Plan: Will keep her in observation overnight. Will administer oral steroids and breathing treatment. CXR ordered and to be taken in the morning.
What E/M code is reported?
99222: This code is used for initial hospital care, per day, for the evaluation and management of a patient, which requires a detailed or comprehensive history, a detailed or comprehensive examination, and medical decision making of moderate complexity.
The documentation shows a detailed history (including HPI, ROS, PMH, SH, and FH) and a detailed examination (covering multiple organ systems). The medical decision making involves the management of an acute asthma exacerbation, which includes admitting the patient to observation status, administering oral steroids, and planning for further diagnostic testing.
CPT Professional Edition, AMA
A patient with malignant lymphoma is administered the antineoplastic drug Rituximab 800 mg and then 100 mg of Benadryl.
Which HCPCS Level II codes are reported for both drugs administered intravenously?
The patient with malignant lymphoma is administered Rituximab (800 mg) and Benadryl (100 mg) intravenously.
Procedure Description:
Administration of Rituximab (800 mg) intravenously.
Administration of Benadryl (100 mg) intravenously.
HCPCS Level II Coding:
J9312: Injection, Rituximab, 10 mg.
For 800 mg, report 80 units of J9312.
J1200: Injection, Diphenhydramine HCl, up to 50 mg.
For 100 mg, report 2 units of J1200.
HCPCS Level II Code Book (current year).
HCPCS Level II coding guidelines for intravenous drug administration.
Patient has esotropia of the right eye and presents to operating suite for strabismus surgery. The physician resects the medial rectus horizontal and lateral rectus muscles of the eye and secures them with adjustable sutures. Extensive scar tissue is noted, due to a previous surgery involving an extraocular muscle. Extraocular muscle is isolated, and the muscle is freed from surrounding scar tissues.
What CPT codes are reported for this surgery?
Esotropia of the right eye: Indicates strabismus surgery is required.
Resection of medial rectus horizontal and lateral rectus muscles: Specific muscles addressed during the surgery.
Adjustable sutures: Used in securing the muscles, indicating specific techniques.
Extensive scar tissue from previous surgery: Requires additional work and isolation.
CPT codes 67314 and 67334 are used to report the resection of two muscles with adjustable sutures (67314) and surgery on an extraocular muscle involving extensive scar tissue (67334).
A complete cardiac MRI for morphology and function without contrast, followed by contrast with four additional sequences and stress imaging, is performed on a patient with systolic left ventricular congestive heart failure and premature ventricular contractions.
What CPT and ICD-10-CM codes are reported?
Procedure: Complete cardiac MRI for morphology and function without contrast, followed by contrast with four additional sequences and stress imaging.
CPT Codes:
75561: Cardiac MRI for morphology and function without contrast material.
75563: Cardiac MRI with contrast and further sequences.
ICD-10-CM Codes:
I50.1: Left ventricular failure.
I49.1: Premature ventricular contractions.
Code Selection Justification: The CPT codes accurately capture the MRI procedures performed. The ICD-10-CM codes represent the diagnoses of left ventricular failure and premature ventricular contractions.
AMA CPT Professional Edition (current year)
ICD-10-CM (current year)
HCPCS Level II (current year)
A patient with Parkinson's has sialorrhe
a. The physician administers an injection of atropine bilaterally into a total of four submandibular salivary glands.
What CPT coding is reported?
Injection of atropine: Atropine is administered to reduce sialorrhea.
Bilateral submandibular salivary glands: The physician administers the injections into the salivary glands.
Total of four glands: Indicates that multiple glands are treated in the same session.
CPT code 64611 accurately represents chemodenervation of the salivary glands, bilateral. The use of -50, -52, or x4 modifiers is not appropriate since CPT guidelines include bilateral procedures in this code without needing additional modifiers or codes.
