Deck 6: Cardiovascular System

Question 1

Case
-T6-2A INITIAL HOSPITAL SERVICES
LOCATION: Inpatient, Hospital
PATIENT: Dennis Deitz
ATTENDING PHYSICIAN: David Barton, MD
CHIEF COMPLAINT: Left-sided substernal pressure not relieved with one dose of Nitro
HISTORY OF PRESENT ILLNESS: This patient is a 69-year-old married gentleman who has long-standing history of coronary artery disease. He underwent coronary artery bypass grafting in 1982, and his most recent hospitalization for his coronary disease was March of this year. The patient indicates that at about 4 o'clock this morning he woke up with some left-sided pressure which was relieved with one dose of nitroglycerin. He seemed to be doing okay today and then about 6 tonight while watching TV he had sudden occurrence of the left-sided pressure and he took another dose of nitroglycerin, but that did not seem to help and because of that, his wife brought him to the hospital. He was not nauseated, but a little bit sweaty. He has been evaluated at clinic, and it was felt that other than the medication there were no other options available. He was not considered a candidate for heart transplant. He has been taking his medication, isosorbide 40 mg (milligram) 3 times a day; furosemide 40 mg daily; lisinopril 40 mg tablet (3/4 tablet) twice a day; enteric-coated aspirin 325 once a day; pravastatin 40 mg daily; ipratropium inhaler 4 times a day; colestipol 1 gram twice a day; atenolol 50 mg daily, and he uses some Lidex cream. He also uses Nitrostat 0.4 mg p.r.n. (as needed). He has no allergies. He is not a smoker. He does have high cholesterol treated with colestipol. He does have hypertension, which has been controlled. His exercise tolerance has gradually been diminishing.
FAMILY HISTORY: Positive for cancer
SOCIAL HISTORY: He is retired from agricultural industry where he worked as a mill operator. He lives with his wife.
REVIEW OF SYSTEMS: SKIN AND NODES: Negative. EYES: He does not have glasses.
NECK: No history of thyroid or carotid disease. CHEST: See History of Present Illness.
HEART: See History of Present Illness. ABDOMEN: Negative. GENITOURINARY:
Negative. MUSCULOSKELETAL AND NEUROLOGIC: Negative.
PHYSICAL EXAMINATION: Generally appears slightly diaphoretic and anxious. BLOOD PRESSURE 160/80, PULSE 80, RESPIRATION 20, and O2 (oxygen) SAT normal. CHEST is symmetrical and clear. No rales, rhonchi, or wheezing. HEART: Fairly regular rhythm with no murmur, thrill, or rubs. ABDOMEN was slightly protuberant. LIVER, KIDNEYS, AND SPLEEN nonpalpable, no masses palpable. Upper and lower EXTREMITIES no clubbing, no edema. His EKG (electrocardiogram) is stable compared to March of this year. It does show T wave inversions in 2, 3, and AVF and occasional PVCs (premature ventricular contractions). CKMB AND TROPONIN were both normal. While in the Emergency Room, he was given 2 additional doses of nitroglycerin, which did not totally resolve his pain, and so he was started on a nitroglycerin drip.
ASSESSMENT:
1. Angina.
2. Coronary artery disease.
3. Hypertension.
4. Hypercholesterolemia.
5. Chronic obstructive pulmonary disease.
PLAN:
1. Admit.
2. Nitroglycerin drip.
3. Will get serial EKG and enzymes.
4. Will increase his isosorbide to 50 mg t.i.d. (three times a day).
5. Will increase his metoprolol to 50 mg b.i.d. (twice a day).
6. Will start him on Plavix 75 mg.
T6-2A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Answer 1

Professional Services: 99221 (Evaluation and Management Services, Hospital) ICD-10-CM DX: I25.119 (Arteriosclerosis/arteriosclerotic, coronary, native vessel, with angina pectoris), I10 (Hypertension/hypertensive), E78.00 (Hypercholesterolemia), J44.9 (Obstruction/obstructed/obstructive, lung disease, chronic), Z95.1 (Status, aortocoronary bypass)
Explanation: During the HPI, the physician documented 7 elements: the location (left side), duration (long-standing history of CAD), timing (4 o'clock, 6 PM), quality (pressure), context (sleeping and watching TV), associated signs and symptoms (no nausea, sweating), and modifying factors (nitroglycerin). There were 9 items reviewed during the ROS, ophthalmologic, cardiovascular, genitourinary, gastrointestinal, musculoskeletal, integumentary, lymph ("nodes"), endocrine (negative thyroid disease), and neurologic for a level 3 or detailed ROS. The PFSH elements were all reviewed for a level 4 or comprehensive PFSH. This is a level 3 or detailed history.
The 4 constitutional items included blood pressure, pulse, respirations, and general appearance, which equal 1 OS. There were 6 BAs reviewed: chest (symmetrical), abdomen (protrudent), and all extremities (no clubbing, counts as 4). There were 4 OSs reviewed: cardiovascular (no edema, heart), respiratory (clear), gastrointestinal (liver, spleen), and genitourinary (kidney). The total number of BAs/OSs examined was 11, which would usually make this is a level 4 or comprehensive examination; however, BAs are not counted for the comprehensive examination. Recounting there was 1 OS for the constitutional elements and 4 OSs noted during the examination.
With a total of 5 OSs, this examination is a level 3 or detailed physical examination.
The MDM contained extensive diagnosis options, moderate data to review, and high risk for a level 4 or high level of MDM.
The detailed history, comprehensive exam, and high level MDM support 99221.
The diagnoses are taken directly from the Assessment section of the report. The Index refers the coder to "arteriosclerosis, coronary" when "disease, artery, coronary" is referenced. Per the AHA Coding Clinic, the coder is to always assume the native artery is diseased unless specified otherwise, (I25.119). Hypertension (I10), Hypercholesterolemia (E78.00), and COPD (J44.9) are all reported.

Question 2

Case
-T6-2B RADIOLOGY REPORT, CHEST
LOCATION: Inpatient, Hospital
PATIENT: Dennis Deitz
ATTENDING PHYSICIAN: David Barton, MD
RADIOLOGIST: Morton Monson, MD
CHEST, SINGLE VIEW, FINDINGS: This examination is compared to a previous examination dated September of this year. This examination is over-penetrated. There is evidence of prior CABG (coronary artery bypass graft). The heart size is mildly enlarged but unchanged when compared with the previous examination. The pulmonary vascular markings appear within normal limits. There is abnormal focal pulmonary density present within the left lung base. Previously, there was some opacity in this area; however, it has increased since the previous examination. This density may be related to atelectasis or infiltrate. This will require correlation with the patient's signs and symptoms.
IMPRESSION:.
1. Cardiomegaly without evidence for congestive failure.
2. Prior CABG.
3. Abnormal focal density (calcification) is present within the left lung base, which may be related to atelectasis or infiltrate.
T6-2B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Answer 2

Professional Services: 71010-26 (X-Ray, Chest)
ICD-10-CM DX: I51.7 (Hypertrophy, cardiac), Z95.1 (Status [post], aortocoronary bypass), J98.4 (Calcification, lung)
Explanation: The chest x-ray is stated to have been a single view. The -26 modifier is appended when reporting the professional service. The diagnoses are taken from the Impression section of the report. The postprocedural status of this patient prior to coronary artery bypass graft can impact the treatment and was mentioned by the radiologist in his report. Knowing when to code or not to code status post (S/P) conditions can be difficult for the new coder. Additional credit can be given for those who correctly identify this Z code.

Question 3

Case
-T6-2C PROGRESS NOTE
LOCATION: Inpatient, Hospital
PATIENT: Dennis Deitz
ATTENDING PHYSICIAN: David Barton, MD
SUBJECTIVE: The patient is feeling good. He is not having any more pressure or pain or shortness of breath. His nitroglycerin drip is off, and he is feeling good and would like to go home.
OBJECTIVE: His vitals have been stable. Telemetry has been good. CHEST is clear. No
rales, rhonchi, or wheezing. NECK: Bilateral palpable carotids. HEART: Regular rate and
rhythm with occasional extra beat. EXTREMITIES: No edema.
His EKG (electrocardiogram) shows no acute ischemic changes.
His CPK (creatine phosphokinase) and troponin are normal.
ASSESSMENT:
1. Angina.
2. Coronary artery disease.
3. Hypertension.
4. Hypercholesterolemia.
5. Chronic obstructive pulmonary disease.
PLAN: We will send him home today on the increased dose of the isosorbide to 50 mg (milligram) t.i.d. (three times a day). He should take the morning and afternoon doses a little bit later to see if that will help avoid problems during the night. Atenolol is bumped to 50 mg b.i.d. (twice a day), and we will start him on Plavix 75 mg daily. We will tentatively see him in the clinic next week. He is to take it easy over the weekend and if he has any problems, he should come in to the emergency room over the weekend.
T6-2C:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Answer 3

Professional Services: 99238 (Evaluation and Management Services, Hospital Discharge) ICD-10-CM DX: I25.119 (Arteriosclerosis/arteriosclerotic, coronary, native vessel, with angina pectoris), I10 (Hypertension/hypertensive), E78.00 (Hypercholesterolemia), J44.9 (Obstruction/obstructed/obstructive, lung, disease, chronic)
Explanation: The documentation supports discharge management. The patient was examined, plans made for treatment and follow-up, and the patient was discharged from the hospital on the date of this service. Typically a summary of the hospital stay is also included in the discharge note; but it was not documented in this case. No indication of the length of time the physician spends in the discharge process is documented in the medical record, so the service is billed at the 99238 level of services, which indicates 30 minutes or less of discharge services. If the physician stated he spent 30 minutes or more in the service, you would code 99239.
The diagnoses are taken from the Assessment section of the report. The Index refers the coder to "arteriosclerosis, coronary" when "disease, artery, coronary" is referenced. Per the AHA Coding Clinic, the coder is to always assume the native artery is diseased unless specified otherwise.
There is a combination code to report arteriosclerosis of the native coronary artery with angina, I25.119.

Question 4

Case
-AUDIT REPORT T6.2 ANGIOPLASTY/STENT
LOCATION: Inpatient, Hospital
PATIENT: Matthew Logan
ATTENDING PHYSICIAN: Leslie Alanda,MD
SURGEON: James Noonar, MD
INDICATION: ASHD
PROCEDURES PERFORMED: Stenting of the LAD and angioplasty of the second marginal
ANGIOPLASTY AND STENT OF THE LEFT ANTERIOR DESCENDING ARTERY: Mach 2.5 guide was used. The patient received intravenous heparin. He was preloaded with Plavix. A BMW was advanced to the LAD. Thereafter, a 3.0 15 balloon was dilated into the LAD. Thereafter, a 3.0 24 Taxus stent was deployed at 15 atmospheres with good angiographic result and no residual stenosis.
ANGIOPLASTY OF IN-STENT RESTENOSIS OF THE SECOND MARGINAL OF THE LEFT CORONARY ARTERY: The BMW wire was advanced to the circumflex, and the stent was dilated with 2.5 20 Quantum Maverick balloon with good angiographic result and no residual stenosis. Distal to the stent, there was a lesion that has a remainder of 20% to 30%, and I was not willing to stent the small vessel that is going to be prone to re-stenosis like it had done previously.
T6.2:
SERVICE CODE(S): 92928, 92929______________________________________
ICD-10-CM DX CODE(S): I25.10_______________________________________
INCORRECT/MISSING CODE(S): _____________________________________

Question 5

Case
-T6-1A OFFICE SERVICES
An established patient presents to the cardiologist's office for a follow-up visit.
LOCATION: Outpatient, Clinic
PATIENT: Bernie Lieberwitz
PHYSICIAN: David Barton, MD
The patient is here for a follow-up visit. He is an established patient with atherosclerotic heart disease, status post atherectomy of the right coronary artery in 1997. He has done very well over the years. Over the past few months, he has not been feeling as well as he used to in the past. He has been getting some exertional chest discomfort that is short lasting. He also is not having as much exercise tolerance as he used to in the past. He had a Cardiolite stress test done in December of last year, where he exercised for 10 minutes and 30 seconds and achieved 103% of his maximal predicted heart rate. The test was negative for ischemia by electrocardiographic criteria. However, unfortunately there was perfusion defect seen within the posterior/inferior wall of the left ventricle, which was predominantly fixed. That was definitely a change when compared to his previous four Cardiolite stress tests.
CURRENT MEDICATIONS:
1. Lipitor 20 mg (milligram) q.d. (every day).
2. Procardia XL 60 mg daily.
3. Niacin 2 g (gram) daily.
4. Zantac 150 mg b.i.d. (twice a day).
PHYSICAL EXAMINATION: Blood pressure is 110/80. Pulse is 84. Head is normocephalic and atraumatic. Neck is supple without JVD (jugular vein distention) or bruit. Lungs are clear to auscultation and percussion. Heart is regular; S1 (first heart sound) and S2 (second heart sound); no S3 (third heart sound) or S4 (fourth heart sound). No clicks, rubs, or murmurs. Abdomen is soft and nontender. Bowel sounds are well heard. Extremities, upper and lower: No edema, cyanosis, or clubbing. CNS (central nervous system): Within normal limits. The patient is alert and oriented to time, place, and person.
ASSESSMENT: This is a patient with known atherosclerotic heart disease as described above. Clinically, he has not felt as well as he has in the past. His pain is somewhat atypical. It is concerning that his Cardiolite stress test now for the first time is showing a defect and this is a new finding since 1997. It is of concern and suggests that perhaps he may have occluded or stenosed his right coronary artery.
RECOMMENDATIONS: We talked about options. These were primarily to try to optimize his medical treatment versus repeat cardiac catheterization and coronary angiography. The patient absolutely would like to go with an angiogram and would like it to be done as soon as possible. The procedure and all the involved risks, as well as the treatment alternatives, were fully explained to him. He would like to proceed.
T6-1A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question 6

Case
-T6-1B OFFICE SERVICES
The same patient as in T6-1A presents for a visit post atherectomy after the days included in the surgical package.
LOCATION: Outpatient, Clinic
PATIENT: Bernie Lieberwitz
PHYSICIAN: David Barton, MD
The patient is here for a follow-up visit. He is a known patient with atherosclerotic heart disease, status post atherectomy of the right coronary artery back in 1997. He has been doing quite well with no complaint of chest pain or shortness of breath. He has been feeling a little bit light headed when getting up from a lying position. Cardiolite stress test last week came back normal.
PHYSICAL EXAMINATION: Blood pressure 122/70. Pulse 68. Head normocephalic and atraumatic. Neck supple without JVD (jugular vein distention) or bruit. Lungs are clear to auscultation and percussion. Heart: Regular S1 (first heart sound) and S2 (second heart sound); no S3 (third heart sound) or S4 (fourth heart sound). No clicks, rubs, or murmurs. Abdomen is soft and nontender. Bowel sounds are well heard. Extremities show no edema, cyanosis, or clubbing. CNS (central nervous system): Within normal limits. The patient is alert and oriented to time, place, and person.
ELECTROCARDIOGRAM is within normal limits.
ASSESSMENT: Coronary artery disease, status post atherectomy. Patient is doing quite well, with normal Cardiolite.
RECOMMENDATIONS:
1. Continue the current medication.
2. Repeat Cardiolite stress test on follow-up visit in one year.
T6-1B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question 7

Case
-T6-1D ANGIOPLASTY/STENT REPORT
LOCATION: Outpatient, Hospital
PATIENT: Bernie Lieberwitz
SURGEON: David Barton, MD
PROCEDURE: Angioplasty/stent of 80% to 90% proximal/mid right coronary artery stenosis
INDICATIONS: Atherosclerotic heart disease
COMPLICATIONS: None
RESULTS: Successful angioplasty/stent of 80% to 90% proximal/mid right coronary artery stenosis with no residual stenosis at the end of the procedure
T6-1D:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question 8

Case
-T6-1E RADIOLOGY REPORT, CHEST
LOCATION: Outpatient, Hospital
PATIENT: Bernie Lieberwitz
PHYSICIAN: David Barton, MD
RADIOLOGIST: Morton Monson, MD
EXAMINATION OF: Chest
CLINICAL SYMPTOMS: Positive cardiac stress test
PA (PULMONARY ARTERY) & LATERAL CHEST, TWO VIEW, 8:30 AM: No comparison films are available. Cardiac silhouette and pulmonary vasculature are within normal limits. No focal infiltrates or pleural effusion is identified. The aorta is mildly tortuous. There is mild linear opacity in the left lung base most likely consistent with some subsegmental atelectasis or scarring. There is mild increase in the interstitial markings in this area.
IMPRESSION:
1. Mild linear opacity, left lung base, most likely consistent with subsegmental atelectasis or scarring.
2. Mild increase in the interstitial markings in the left lung base. This may be chronic, but without comparison films, acute process, including infection, cannot be excluded.
T6-1E:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question 9

Case
-AUDIT REPORT T6.1 CARDIAC CATHETERIZATION REPORT
LOCATION: Inpatient, Hospital
PATIENT: Matthew Logan
ATTENDING PHYSICIAN: Leslie Alanda, MD
SURGEON: James Noonar, MD
PROCEDURES PERFORMED: Right and left coronary angiogram, LV-gram left heart.
INDICATION: Unstable angina
HEMODYNAMICS:
1. Aortic pressure is 142/74.
2. LV pressure is 142/20 with no gradient on pullback.
VENTRICULOGRAM: Ventriculogram showed normal LV size. There is an inferior wall hypokinesis with an ejection fraction of 55%.
CORONARY ANGIOGRAM:
RIGHT CORONARY ARTERY: The right coronary artery is totally occluded in its proximal third. There is a large stent deployed from the proximal right coronary artery all the way close to the distal third that has in-stent restenosis with total occlusion and with TIMI-0 flow, and preobstructive collateral from the conus branch filling and the distal right coronary artery.
LEFT MAIN CORONARY ARTERY: The left main is normal.
LEFT ANTERIOR DESCENDING ARTERY: The left anterior descending artery has in its proximal third plaque that appears to be eccentric and severely obstructive. The left anterior descending artery thereafter has no significant disease. It gives rise in the midportion to a small diagonal that has no significant obstruction.
CIRCUMFLEX ARTERY: The circumflex artery as rises from the left main is trifurcate. The first marginal is diffusely diseased and in its midportion has a 50% to 70% stenosis. Thereafter, the circumflex bifurcates there to give two branches, the first of which is small in size and has a 50% stenosis in its proximal third, and the second marginal has a stent placed in it with severe in-stent restenosis.
IMPRESSION/CONCLUSION:
1. Preserved systolic function with inferior wall severe hypokinesis (decreased mobility).
2. Total closure of the right coronary artery with this in-stent restenosis of a very long stent placed in the proximal right coronary artery with very obstructive collateral filling from the conus branch to the distal right coronary artery that appears to be small.
3. Disease in the proximal left anterior descending artery.
4. In-stent restenosis of the second marginal and diffuse disease in the small marginal.
RECOMMENDATIONS: At this point, my recommendation is to percutaneously revascularize the left anterior descending artery as well as the in-stent restenosis of the circumflex.
The right coronary artery is currently totally occluded with preobstructive collateral filling the right coronary artery. (Restenosis of the stent is a complication of a cardiac implant NEC.)
T6.1:
SERVICE CODE(S): 93453____________________________________________
ICD-10-CM DX CODE(S): I25.110______________________________________
INCORRECT/MISSING CODE(S): _____________________________________