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Not sure about anyone else out there, but my mouth is part of my body. At least last time I checked. It’s been right there on the front of my face for as long as I can remember. Now, come to think of it, I am sure about everyone else. I have yet to see […]
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Need some help to find why, N85.00 can’t be coded with N86. There is an exclude 1 note in the ICD 10 guidelines; however, while informing our doctors they want to know the reason. Our OB saying, these two conditions doesn’t have any relation, then why we can’t code together.:confused:
highly appreciate your help in this regards,
Thanks a lot
Sherin
Any help or guidance to the information would be great.
I am trying to find a document or something in writing that states when the E/M code is appropriate to be with a 12002 and when it is not.
Thank you,
Aimee 😉
Can you please help me to code this ob encounter?
Scenario:
An established patient visited the clinic for her initial antenatal care. She is currently 15 weeks pregnant (G2,P1) with previous cesarean section due to breech presentation. This is a spontaneous pregnancy. Patient has currently no complaints. No nausea, no vomiting, no abdominal pain, no vaginal bleeding. She is a known case of Uterine Fibroid, and Iron Deficiency Anemia. Patient is taking oral iron replacement. No surgical history, negative family history. The physician requested dating scan and booking investigation for the patient.
I hope you can help me with this.
Thank you!!!
:):)
PROCEDURES:
1. Right heart catheterization with shunt study.
2. Arterial line placement.
INDICATIONS:
Hypoxemia
COMPLICATIONS:
None
DESCRIPTION OF PROCEDURE:
A full PARQ discussion was held with the patient and informed consent was obtained. All questions were answered. He asked us to proceed. He was brought to cardiac catheterization lab, prepped and draped in the usual manner. Local anesthesia given. An 8-French sheath was placed into his right internal jugular vein using direct ultrasonic guidance. Fluoroscopy also confirmed position of the wire prior to sheath insertion. A right radial artery line was then placed using an Angiocath 0.021-inch angled guidewire. The patient was on 3 L nasal cannula for the shunt study. An 8-French Swan-Ganz catheter was then slowly advanced under fluoroscopy into the right atrium, right ventricle, pulmonary artery and pulmonary capillary wedge positions. Pressures recorded in each of these positions. Cardiac output and cardiac index were measured both using thermodilution and Fick methods. Oxygen saturations were also drawn using the Swan-Ganz catheter in the SVC, IVC, high RA, mid RA, low RA, RV base, RV apex, RVOT, main PA, RPA, and wedge positions. Arterial saturation was also drawn from the A line. This was all done on oxygen. In order to enter the inferior vena cava, a 5-French multipurpose diagnostic catheter was advanced over a 0.035-inch angled guidewire into the IVC. IVC saturation was drawn with the multipurpose catheter. The patient then underwent a repeat wedge saturation and arterial saturation on room air. The patient’s O2 saturation on pulse oximetry dropped initially to the 75-78% range within 2 minutes of oxygen discontinuation. After saturations were drawn, peripheral oxygen saturation dropped to as low as 68%. Because of this, oxygen was turned back up to 3 L nasal cannula and a repeat shunt study was not performed on room air. The sheath was removed and hemostasis achieved using manual compression. The patient tolerated the procedure well. There were no complications.
SUMMARY:
1. Mildly elevated right-sided filling pressures with mean RA pressure of 10 mmHg and pulmonary capillary wedge pressure of 17 mmHg.
2. Mean pulmonary artery pressure of 33 mmHg.
3. Normal cardiac output and cardiac index by thermodilution and low-normal cardiac output and cardiac index by Fick methods.
4. No significant left-to-right cardiac shunt is seen.
5. A 9-10% oxygen saturation drop is seen between the pulmonary capillary wedge positions and peripheral arterial saturations consistent with right-to-left shunt.
6. The patient’s hypoxemia is likely related to both cardiac and non-cardiac contributions. The patient was significantly hypoxemic on room air with a pulmonary capillary wedge saturation of 86-87%. This suggests underlying hypoxemia from pulmonary causes. However, the patient also has cardiac etiologies for hypoxemia, including a 9-10% oxygen saturation drop between the pulmonary capillary wedge position and right radial artery consistent with a right-to-left shunt.
7. Mild fluid overload may also contribute.
I came up with 93451 (RHC), and 36620 (arterial line placement). I’m not sure on the shunt study though. Am I on the right path with those?
Thanks for any and all comments!
Findings: EGD: Normal esophagus, stomach, duodenum. No stent
seen exiting the ampulla. EUS: Linear EUS performed via
esophagus, stomach, duodenum. There is a hyperechoic metal bile
duct stent with acoustic shadowing seen within the CBD. The
common hepatic duct proximal to the CBD stent is normal in
appearance without stones. No gallbladder seen. Homogeneous
pancreas without masses. PD is normal in course and caliber
measuring 1-2 mm in the body of the pancreas. Few 4-6 mm
well-defined, triangular lymph nodes which are mostly hypoechoic
with hyperechoic center. Normal left lobe of liver. Normal
peripancreatic vessels including celiac axis. Normal left
adrenal gland, left kidney spleen. ERCP: TJF scope was used.
Ampulla with signs of previous sphincterotomy but no stent seen
exiting the ampulla. Stent is also visualized on fluoroscopy
and had clearly migrated proximally into the bile duct.
Selective bile duct cannulation easily achieved using balloon
tipped catheter loaded with 0.025 in guidewire. Bile aspirated.
Balloon sweep performed using 11.5 mm balloon to try to move
metal bile duct stent more distally but the balloon removed
moderate amount of stone debris from the stent/bile duct without
moving the bile duct stent. Then, we dilated the ampulla/distal
bile duct using TTS CRE balloon to maximum of 10 mm to help
facilitate stent removal. Following dilation of distal bile
duct/ampulla, the dilation balloon was inflated within the metal
stent and this allowed the metal stent to be moved distally such
that the distal aspect of the stent was now visible outside the
ampulla. The dilation balloon was deflated and removed. Then,
the metal stent was grasped using rat tooth forceps and removed
from the mouth. The scope was reintroduced and selective bile
duct cannulation achieved again using balloon tipped catheter.
Multiple balloon sweeps performed using 8.5 and 11.5 mm balloons
with removal of small amount of stone debris. Occlusion
cholangiogram showed CBD measuring 7-8 mm without any evidence
of leak, stricture or filling defect. Contrast drained very
well. Multiple balloon sweeps performed to clear any residual
contrast. Excellent drainage of bile and contract at the end of
the case. Pancreatic duct intentionally not cannulated and
pancreatogram intentionally not performed. I personally
interpeted all fluoroscopic imaging of bile duct as described
above.
Endoscopic Diagnosis: 1) Proximally migrated fully covered
metal bile duct stent (seen on EUS). 2) ERCP with bile
duct/ampulla balloon dilation, stone debris removal, metal bile
duct stent removal. Cholangiogram shows no further bile duct
stricture, leak or bile duct stones.