Help, Help, Help

daniel

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I work for a Multi-Specialty practice. Focusing on just basicly E/M coding. But once in awhile I get these report dropped on my desk. Need some guidance on how to code this report. Thank You in advance.


Dictation

Date of operation/procedure

Indication:
1) Recurrent chest pains
2) Recurrent admissions to hospital for chest pain and possible unstable angina.
3) Risk factors for coronary arterial disease



HPI:
The patient was brought to the holding room and Adenosine intravenous was infused over 6 minutes. In the middle at the end of 3 minutes, the Cardiolite intravenous was injected. During the infusion the patient had severe chest pain. She was nauseous. She was having shortness of breath. Oxygen was started. Ekg did not show any charges. Blood pressure was appropriate. No arrhythmia was noted.

Conclusion:
1) Adenosine infusion tolerated well.
2) Atypical chest pain noted.
3) Appropriate heart rate and blood pressure response with an adenosine
4) Cardiolite reprot to follow separately from nuclear medicine department.


Thank you In advance for the help
Daniel CPC
 

Davistm

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There are some things that are not clear about this procedure. It sounds as if the patient was in a hospital facility [ER?] and that the "nuclear medicine department" conducted the test and a physician interpreted it.

Assuming the above scenario is correct, this sounds like a myocardial stress test with the stress pharmacologically induced - limited study, no wall motion, no ejection fraction. Facility will bill for the technical component, radiopharmaceuticals and stressing agent. The physician [yours?] will bill the professional component: 78464-26, 93010.

If this scenario is not the correct one, give me the correct "set up" and I will look at the coding again.

Terry
 

daniel

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Well this all that was given to me, so in your opion what would you do. Meaning coding wise. I mostly code the family pratice side of things over her E/M and minor procedure. Once in awhile I get this registration face sheet dumped on my desk, and I have to request this op report that goes with it from the hospital, like the one shown her. So this is all I have.

Daniel
CPC

P.S- if this helps, there's some similar op reports, one reads
Adenosine-Cardiolite Stress Test.
 

Davistm

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Daniel,

I would not submit coding based on the documents you have. I would require a better description of what was done, where it was done and who did it.

Terry
 

007CPC

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Amp the documentation

Hello Daniel! According to your high risk factors, the patient sounds like their headed down a high morbid, eventually mortal direction. With the sever conditions that are substantiated on this dictation, you could most definitely code this at a level 5; but the providers rhetorical tone of this dictation sounds like a RN or LPN wrote it! If your providers were aware of all the three coding elements and their subelements, if documented efficiently, it most definitely could fit a level five.

Tell your doctor to get a miniature hand recorder.

p.s. This isn't an op report
 
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