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2018 CPC Practice Exam Answer Key 150 Questions With Full Rationale (HCPCS, ICD-9-CM, ICD-10, CPT Codes) Click here for more sample CPC practice exam questions with Full Rationale Answers

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Split thickness graft/hidradenitis excision axilla- need advice :)

Hello, I am unfamiliar with split thickness graft. I am leaning towards coding the below as 11450-50, 15120,15120. The wound vac is bundling. any thoughts or advice is appreciated. :)

SCDs were placed on bilateral lower extremities. arms were outstretched on padded foam arm rests and abducted to less than 90 degrees at the shoulder. underwent general anesthesia. was prepped and draped in the usual sterile fashion. I began by injecting 150 cc of a mixture of 266 mg exparel in 20 cc and 50 cc 0.25% marcaine diluted in 100 cc normal saline split equally as a field block into bilateral axillas and left anterolateral thigh. Her right axilla was then marked and it is 16 x 13 cm area of skin with skin pits, scarring and nodularity. This is also the hairbearing area of her right axilla. It was incised down into the subcutaneous fat and removed with cautery. The skin was sent to pathology for examination. Hemostasis was achieved. The wound was irrigated with normal saline. Using a 2-0 Vicryl pursestring suture in the dermis the wound was narrowed to dimensions measuring 10.5 x 6 cm in preparation for skin grafting. Attention was then turned to the left axilla. The same procedure was performed. On the left side to the area marked for excision measured 15 x 12 cm. After the Vicryl pursestring suture I was able to narrow the dimensions down to 10 x 6 cm. The left anterolateral thigh was then prepared for graft harvest. A dermatome mesher was used with a 4 inch blade. A 1/12 inch thick skin graft was harvested after applying mineral oil. It was meshed at a 1-1.5 ratio. 2 10 cm long passes were made with the 4 inch wide blade. The grafts were sewn into the axillas using a 5-0 chromic running suture. The donor site was dressed with Xeroform, Tegaderm, ABD and Ace wrap. Adaptic and black foam wound VAC spongewere placed over the axillary skin grafts. Both of the back to her bridged to beneath her clavicles. The VAC’s were then connected through Y adapter to a single machine and set at 125 mm of continuous pressure. The system was functioning with a slight leak but was holding pressure. Patient was then awakened from anesthesia without complication and transferred to the recovery room in stable condition. At the end of the case all the needle, sponge and instrument counts were correct x 2 and I was present for the entire case.

thank you so much

Medical Billing and Coding Forum

need help with failed pci coding

Conclusion

This patient with prior treatment for coronary artery disease status post PCI ostial RCA x2, hypertension, dyslipidemia, severe aortic stenosis status post TAVR using a Medtronic valve has been complaining of substernal chest discomfort. Patient underwent Lexiscan stress test revealing evidence of anterior wall ischemia. Left heart catheterization was recommended.
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After obtaining informed consent, the patient was prepped and draped in sterile fashion. A 6 French glide sheath was inserted in the right radial artery. Radial cocktail consisting of 2.5 mg of verapamil and 200 mcg of nitro was administered via right radial artery sheath to prevent radial artery spasm. A 6 French Tiger catheter and Judkins right coronary catheters was used for left and right coronary angiography. TR band was placed on the right radial artery access site for patent hemostasis.
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I attest that moderate conscious sedation was provided under my direct supervision with the sedation trained nurse using 1 mg of intravenous Versed and 50 mcg of fentanyl to sedate the patient. Start time 11:06 AM and end time was 12:17 PM. There were no complications. See nurse’s sedation sheet, for complete pre-and post service details.
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Hemodynamics:
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The left ventricular pressure was 30 mmHg. The aortic pressure was 132/61 mmHg.
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Coronary Angiography:
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Right coronary artery large caliber dominant vessel with patent ostial proximal stent with mild mid 20-30% stenosis, distal tubular 90 to 95% stenosis. It gives rise to small to medium caliber RPDA and RPL branches with mild luminal irregularities.
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Left Main coronary artery is patent.
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Left anterior descending is a large caliber vessel with mild proximal disease, mild 30% mid vessel stenosis, patent distal vessel. There is a 1 major diagonal branch is of medium caliber with mild luminal irregularities.
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Left circumflex is a large-caliber nondominant vessel with luminal irregularities. Obtuse marginal 1 is a small caliber vessel with luminal irregularities. Obtuse marginal 2 is a large caliber vessel with mild diffuse disease.
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Left ventriculogram: Left ventricular cavity was entered using 6 French guide catheter and LVEDP was measured at 30 mmHg.
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The patient was then transferred to the recovery area in stable condition:
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Summary conclusion:
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1. Severe 1 vessel CAD involving the distal RCA.
2. History of coronary disease status post PCI of ostial RCA x2
3. Severe aortic stenosis status post TAVR using a Medtronic valve
4. Hypertension
5. Dyslipidemia
6. Obesity plan
7. Atrial fibrillation
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Recommendation:
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Recommend PCI of distal RCA.
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6 French Williams right diagnostic catheter was used to engage RCA. She was anticoagulated using 80 units/kg heparin. 300 cm run-through wire was advanced into distal RCA. Catheter was exchanged for a 6 French JR4 guide with sideholes. Attempting delivering a 2.5 x 15 mm balloon which was unsuccessful. This was an extremely difficult cannulation of right coronary artery with history of ostial stents and Medtronic core valve implantation. Procedure was aborted at this time. Diagnostic angiography revealed TIMI-3 flow without any evidence of dissection or perforation. ACT measured during the procedure was 245. Patient received another 1000 units of heparin.
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Recommend plan PCI of distal RCA via right common femoral artery approach. We may use either hockey-stick versus AR mod guide.
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thanks in advance
should I only bill 93458 or failed intervention with 74 modifier?

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Medical Billing and Coding Forum

need b/l iliac stenting help

Conclusion

This 53-year-old female has a known left common iliac artery occlusion status post failed attempt with an antegrade approach from the left femoral was brought in today for attempt from the left brachial. Procedure, risks, benefits, alternative options were explained. Risks including bleeding, infection, cerebrovascular accident, myocardial infarction, death, and arrhythmia were all explained patient was agreeable. He was brought into the cardiac cath lab where conscious sedation (moderate sedation) was performed by myself using Versed and fentanyl. Conscious sedation was started 8:26 AM and monitoring period Ended 10:16 AM. I was present throughout this whole entire period With the patient. Both groins were prepped and draped in the usual fashion. 2% lidocaine was used to anesthesize the skin. Using modified Seldinger technique, a 6 French sheath was inserted in the right femoral artery and the left brachial artery. A long destination sheath was inserted from the left brachial artery into the distal aorta at the bifurcation. The 6 French sheath from the right femoral artery was also a long sheath that was advanced to the distal aorta. .
Finding:
1: Repeat angiogram did show the occlusion in the left common iliac artery. There is barely any knob.
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Intervention:
With a support of an angled 4 French glide catheter, allowing zip wire was able to cross the occlusion all the way to the common femoral artery. The glide catheter was advanced over it. The wire was removed and angiogram so the catheter showed that we were all intraluminal. A V 18 wire was then used and advanced into the left superficial femoral artery. The catheter was then removed. The occlusion was dilated with a 5 x 80 mm balloon. As the occlusion was proximal, I decided to perform kissing stenting as I could not ensure that the stent placement in the origin of the common iliac artery would not impinge on the origin of the right common iliac artery. Since the occlusion is long I covered the distal occlusion with a 8 x 60 mm epic self-expanding stent. Following that simultaneous 8 x 27 mm express of the balloon-expandable stents were placed in the origin of bilateral common iliac artery in a kissing fashion with excellent result and no residual stenosis
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*
Impression:
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100% occlusion of the origin of the left common iliac artery. I placed a 8 x 80 mm epic self-expanding stent in the common iliac artery. The origin of bilateral common iliac arteries were covered with an 8 x 27 mm express LD balloon expandable stents in a kissing fashion
Plan: Continue medical treatment with dual antiplatelet therapy and aggressive risk factor control

thanks in advance
am I only coding 37221-50 or should I add 37223-lft also?

Medical Billing and Coding Forum

SNF therapy contracts: Your risks and what you need to know

SNF therapy contracts: Your risks and what you need to know

Q: How long does the SNF need to retain background and licensing documentation of the therapist working for a contract company?

 

A: The SNF needs to retain background and licensing documentation of the therapist for a contract company for the same amount of time as it does for its employees. You should follow whatever your record retention requirement is for your employees, and there should be a statute of limitation within your state. Usually if the therapist was there, involved in the care and treatment of patients, and anything comes up, there’s no statute of limitation you should know.

With billing fraud, there’s no statute of limitation. On any kind of care fraud, or any kind of abuse and neglect, if those issues arise, I typically suggest that if you’ve got a seven-year statute of limitation, you maintain records for seven years.

 

Q: Do you recommend shared risk or indemnification clauses for Medicare consultants who come in and make recommendations on RUG levels?

A: Yes, I recommend shared risk clauses for consultants who come in, especially if they’re going to come in on a preemptory basis and decide the RUG levels you should bill. I do expect shared risk. Anybody who’s involved in that Medicare billing process is going to have input into what we bill. That is a contractor separate from the SNF. The SNF can’t essentially indemnify itself. But if the SNF is using somebody to do any of that work and be part of the coding, part of the auditing, and ultimately part of the RUGs, you need to be part of that process of indemnification.

SNF providers need to be part of that process of shared risk?the only way I could make sure that I can indemnify the SNF for the activities of its contractors and anybody who is part of that process is to say, “If you’re going to give me advice and you’re going to be part of this and you’re going to say, ‘Yeah, I’m an expert, I know what ought to be billed, etc.’ and I have to rely on that, my answer is, ‘Okay, I’m happy to do that, but here’s the deal. If in fact you’re wrong and this turns out to be incorrect, you’re going to be responsible for the losses. And at least a portion or a portion thereof, and we’re going to have some shared risk and indemnification as well.’ ”

HCPro.com – Billing Alert for Long-Term Care

Need Podiatry Coding Help **URGENT**

Hi Everyone –

Can someone please assist with coding this visit note? I am getting 5 different answers from my coding team of 5 coders.

99212 – is this separately reportable, why or why not?
11720 – is this separately reportable, why or why not?
G0127-XU – is this separately reportable, why or why not?

In your opinion, what would be the final coding. See attachment.

This is for WYOMING MEDICARE
https://www.aapc.com/memberarea/foru…&thumb=1&stc=1

Thanks in advance for any help with this.

Attached Images

Medical Billing and Coding Forum

Need Help Coding Podiatry Office Visit

Hi Everyone –

Can someone please assist with coding this visit note? I am getting 5 different answers from my coding team of 5 coders.

99212 – is this separately reportable, why or why not?
11720 – is this separately reportable, why or why not?
G0127-XU – is this separately reportable, why or why not?

In your opinion, what would be the final coding.

Link to office visit note: https://drive.google.com/file/d/1IvO…ew?usp=sharing

This is for WYOMING MEDICARE

Thanks in advance for any help with this.

Medical Billing and Coding Forum

Need professional coder in Rhode Island

Medical Billing and Coding Forum

Need help with a colectomy procedure, please :)

WOULD YOU CODE AS 44143,44139?

PROCEDURE: Exploratory laparotomy. Rectosigmoid resection. Mobilization of the right colon, hepatic and splenic flexures. Debridement of right retroperitoneal space.

A standard midline incision was performed. Prior to entering the peritoneal cavity, there was a purulent infection noted coming from the right lower quadrant and right mid abdominal retroperitoneal space. Upon entering the abdominal cavity, there was murky peritoneal fluid but no obvious succus entericus identified. The omentum was matted and fixed to a pelvic inflammatory/neoplastic mass. The omentum was mobilized by dividing it between Kelly clamps and tying off with 0 silk suture. Loops of the terminal ileum or fixed to the mass as well but not incorporated by it. The inflammatory adhesions were taken down freeing the small intestine from the pelvic mass.
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Once it was decided that the the pelvic mass was the probable source of perforation and sepsis and resection was eminent, the right hemiabdomen was explored by mobilizing the right colon. There was evidence of a previous appendectomy. The right ureter was identified. There was a foul-smelling diffuse infectious process involving the soft tissues of the right retroperitoneum, incorporating the renal space. The hepatic flexure was mobilized and the duodenum exposed. There is no bile staining in the sub-hepatic space and the duodenum appeared intact and without inflammation as did the stomach and gallbladder. The NG tube was palpated. The liver appeared normal. There is a small hemangioma in the left hepatic lobe. The necrotic tissue of the right retroperitoneal space was excised.
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The small bowel was run from the ligament of Treitz to the ileocecal valve and there is no evidence of perforation or malignancy. The transverse colon was palpated and normal. The left colon–sigmoid colon junction was then divided with a TA stapler. Mesentery was scored medially and the left colon/sigmoid avascular line was incised to fully mobilize the left colon and sigmoid. The sigmoid colon mesentery was divided between Kelly clamps and tied off with 0 silk suture. Left ureter was identified and protected. The inflammatory–possibly neoplastic mass was then mobilized from the pelvic sidewall. Upon dividing the dense tissue surrounding the mass, a small colotomy was created. The posterior rectal space was entered allowing for isolation of the lateral stalks that were divided under direct vision using sharp dissection and cautery. The inflamed anterior space was entered as well allowing for the contour stapler to encompass the superior rectum for excision of the rectosigmoid. 0 Prolene sutures were placed on the lateral aspect of the superior rectum for future identification. The left colon was viable and mobilized to the splenic flexure.
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Anesthesia department reported difficulty maintaining the patient’s blood pressure despite maximum fluids and pressor agents. Therefore the decision was made to irrigate the abdomen with several liters of warm saline and to place an AB Thera device for closure and to take the patient back for a second look in 24-48 hours. There was diffuse oozing from the right retroperitoneal space. Upon mobilizing the liver by dividing the ligamentum teres, there was a small tear made in the left lobe that was cauterized and a small piece of Surgicel placed for hemostasis. Otherwise there is no significant bleeding. Sponge needle count was correct. The abdomen Ab Thera was placed to vacuum suction with a good seal. The patient was then taken to the intensive care unit intubated and stable but in critical condition.
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Medical Billing and Coding Forum

need help with vein graft balloon angio only

PROCEDURES
1. Coronary angiogram
2. Left heart catheterization
3. Graft angiogram
4. Percutaneous intervention and balloon angioplasty of vein graft to OM1.
5. Right iliofemoral angiogram

PROCEDURE NOTE
Informed consent was obtained after explaining risks and benefits to the patient. Right groin was draped and prepped in a sterile fashion. Patient was premedicated with 1.5 mg Versed and 100 mcg fentanyl IV. After injecting 2% lidocaine, right common femoral artery was accessed with the help of micropuncture with some difficulty due to previous scarring and 6 French femoral sheath was inserted. 6 French diagnostic catheters were used to cannulate left and right coronary artery. 6 French FR 4 catheter was also used to cannulate the vein grafts. Patient was proceeded with intervention of the vein graft of obtuse marginal branch. Overall patient tolerated procedure well. Right iliofemoral angiogram was performed and femoral sheath was pulled and manual pressure was applied for 20 minutes with good hemostasis. FemoStop was applied at Bell pressure for persistent hemostasis.
*
LEFT HEART CATHETERIZATION
Left ventricular end diastole pressure was 18 mmHg. No significant gradient across aortic valve.

CORONARY ANGIOGRAM
1. Left main was calcified with 70-80% distal stenosis.

2. Left anterior descending artery had severe diffuse disease proximally before it was 100% occluded for previous stents

3. Left circumflex artery was 100% occluded proximally

4. Right coronary artery was under percent occluded at the origin.
*
GRAFT ANGIOGRAM
1. Vein graft to LAD was under percent occluded (chronic)
2. Vein graft to RCA was patent. Stent was noted in the mid body of the graft which was patent with 80% in-stent restenosis. 50-60% stenosis noted in distal RCA after anastomosis before the bifurcation of PDA and PLV branches. PDA branch was patent with no significant disease given collaterals to distal LAD. PLV branch was patent.
3. Vein graft to obtuse marginal branch was patent with TIMI II antegrade flow. Stent at the ostium had 99% in-stent restenosis. There was also 80-90% stenosis of mid part of the body of the graft within the previous stent. Distal part of the vein graft was patent.
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PERCUTANEOUS INTERVENTION OF VEIN GRAFT OBTUSE MARGINAL BRANCH
6 French JR4 guide catheter was used to cannulate the vein graft to OM 1. Heparin was used for anticoagulation. Initially filter wire was attempted for distal protection which was unsuccessful to advance due to significant ostial stenosis. 0.014 BMW guidewire was advanced and vein graft to OM stenosis was successfully crossed without difficulty. 2.5 x 15 mm noncompliant balloon was advanced and both lesions of vein graft was predilated at 16 followed by 18 atm. Nitroglycerin intracoronary was given. Subsequent angiogram revealed TIMI-3 antegrade flow and distal part of the body of the graft but still residual significant stenosis at the ostium. 3.5 x 15 mm noncompliant balloon was advanced and both lesions of vein graft were dilated at 16 atm couple of times. Adenosine followed by nitroglycerin were given through guide catheter. Subsequent angiogram revealed wide-open vein graft to OM with TIMI-3 antegrade flow and no evidence of dissection or perforation. No evidence of distal embolization. Patient was hemodynamically stable and asymptomatic at the end of procedure.

RIGHT ILIOFEMORAL ANGIOGRAM
Right common femoral artery was patent. Sheath insertion was just below the origin of the inferior epigastric artery..

IMPRESSION
1. Severe native 3 vessels coronary artery disease.
2. Patent vein graft to OM1 with 99% ostial stenosis within the stent as well as 80% instent restenosis within the mid body of the graft. (Likely culprit)
3. Patent vein graft to RCA with 80% in-stent restenosis.

RECOMMENDATIONS
Patient has complex coronary disease as described above. He had multiple intervention of vein graft in the past including 3 intervention in vein graft to OM last year. He has significant instent restenosis of drug-eluting stents. Recommend evaluation by cardiac surgery for possible redo CABG. Continue aggressive medical treatment.
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should I do 93459,92937 -lc since this is vein graft balloon angio or 92920? I bill for hospital
thanks in advance

Medical Billing and Coding Forum