The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck

Exercise 1

Case 2-1
LOCATION: Outpatient, Hospital
PATIENT: Gordon Monday
ORDERING PHYSICIAN: Laddie N. Noss, MD
ATTENDING/ADMIT PHYSICIAN: Laddie N. Noss, MD
RADIOLOGIST: Morton Monson, MD
PERSONAL PHYSICIAN: Ronald Green, MD
EXAMINATION: Bilateral laser-Doppler test.
CLINICAL SYMPTOMS: Peripheral angiopathy due to diabetes.
BILATERAL LASER-DOPPLER TEST: The patient is an 84-year-old man with diabetes and renal disease. He had an arterial Doppler 6 months previously that showed bilateral disease and calcified vessels. The right side showed a digital pressure of 70. The left side was more abnormal with a digital pressure of only 12. Again, vessels were calcified. On the left side, the toe pressure is 35, which is right at the borderline of healing. Transmetatarsal is at the same level. Above the ankle, paradoxically, the pressure is even a little lower at 30, which is right at our threshold. On the right side at the toe, the level is 70, which indicates a good likelihood of healing. Transmetatarsal the level is 60 and above the ankle is 50, all of which should be adequate for healing.
The laser-Doppler studies basically back up the digit pressures. The right side looks abnormal, but adequate for healing. The left side is marginal. Laser-Doppler levels look a little better than the digit pressures regarding this area.
CPT Code(s): _________________
ICD-10-CM Code(s): _________________
Abstracting Questions:
1. Does the laser description affect the CPT code selection for the Doppler scan? _________________
2. Is CPT code selection affected by type (arterial or venous) of study? _________________
3. Does bilateral versus unilateral affect CPT assignment? _________________