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expert please

  1. #1
    Default expert please
    Medical Coding Books
    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

  2. #2
    Default
    Quote Originally Posted by daniel View Post
    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

    Daniel,

    Take a look at these codes... we normally bill 78465-26, 78478-26, 78480-26 (assuming your physicians are only reading the report and do not own the equipment) I can't say for *sure* those are the codes you would use ... I would have to see the report from the nuclear medicine department as indicated on #4 in your conclusion.

    If you can, I would call the nuclear department and ask what they bill. If you can get that information, bill the same codes with the 26 modifier.

    Hope that helps you...

  3. #3
    Default
    Quote Originally Posted by daniel View Post
    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
    They DID do a nuclear medicine exam (likely 78465, 78478, 78480), but this is the report for only the stress portion of that exam, not for the imaging. The coding for the nuc med imaging - the CPT codes referenced above - will come from the nuc med department, and you'll need their report in order to accurately code the 784xx series codes.

    The codes you want to look at for the report above are:

    93015 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report
    93016 physician supervision only, without interpretation and report
    93017 tracing only, without interpretation and report
    93018 interpretation and report only

    The April 1996 CPT Assistant states:

    To report physician supervision and/or interpretation only of a cardiovascular stress test performed using institution-owned equipment, use codes 93016 or 93018 (in conjunction with the codes for the diagnostic procedure, e.g. 78465).

    Provision of a stress test by a physician in an office or other setting in which the physician owns the equipment, supervises the stress test, and provides the interpretation of the results of the test is reported with CPT code 93015.

    To report the technical component of cardiovascular stress testing (e.g. hospital), use code 93017 in addition to the primary diagnostic procedure code(s).
    Stacy Gregory, CPC, CCC, RCC

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