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SUBJECT:HIM205 Chart Auditing

 

Case 3-1
Interventional radiologists perform both the procedure and the radiologic services, so you will report both the procedure and radiology services.

LOCATION: Outpatient, Hospital

PATIENT: Mike Morgan

PRIMARY CARE PHYSICIAN: Ronald Green, MD INTERVENTIONAL RADIOLOGIST: Edward Riddle, MD

EXAMINATION: CT-guided liver biopsy.

CLINICAL SYMPTOMS: Liver mass.

CT-GUIDED LIVER BIOPSY: Informed consent was obtained. The patient was placed supine on the CT table, and axial CT was performed to localize the low-density lesion within the dome of the liver medially. The right mid-axillary line skin was prepped and draped in the usual sterile fashion. The skin and subcutaneous tissues were infiltrated with 1% lidocaine. A 19-gauge coaxial needle was advanced into the low-density lesion, and axial CT was performed to confirm needle position prior to biopsy. Four 20-gauge core biopsy samples were obtained. Biopsy samples were obtained using a 20-gauge Monotype biopsy gun. The biopsy gun and coaxial needle were removed.

The patient did not receive conscious sedation. His pulse oximeter and vital signs were monitored throughout the exam. There were no complications. He tolerated the procedure well and left the radiology department in stable condition.

IMPRESSION: Successful and uncomplicated CT-guided biopsy of a low-density mass within the dome of the liver medially.

Pathology Report Later Indicated: Primary malignancy of the liver.

CPT Code(s):__________________________
ICD-10-CM Code(s): ____________________

Abstracting Questions:
1. What technique was used to accomplish the liver biopsy?_________________________
2. What type of radiological guidance was used?___________________________________
3. Is the radiological guidance reported separately?________________________________
4. Was sedation administered? _________________________________________________
 

 

Case 3-2
LOCATION: Inpatient, Hospital

PATIENT: Benito Castro

ORDERING PHYSICIAN: Gregory Dawson, MD ATTENDING/ADMIT PHYSICIAN: Gregory Dawson, MD

RADIOLOGIST: Morton Monson, MD

PERSONAL PHYSICIAN: Ronald Green, MD

EXAMINATION: Placement of a tunneled hemodialysis catheter. CLINICAL SYMPTOMS: End-stage renal disease.

PLACEMENT OF TUNNELED #14.5 FRENCH HEMODIALYSIS CATHETER: The patient is a 62-year-old male with a history of renal failure. Placement of a tunneled hemodialysis catheter was requested by Dr. Green.

Prior to the start of the study, the procedure was explained to the patient, including the risks, complications, and alternatives. The patient understood and consented to the exam.

The patient was prepped and draped in the usual sterile fashion. An Ioban II (antimicrobial film) was placed on the skin. A 21-gauge micropuncture needle was advanced into the right internal jugular vein in the lower neck region using sterile technique under ultrasound guidance following administration of local anesthesia (1% lidocaine). Utilizing the Microvena kit, a 0.18 stainless steel wire was used to measure the distance from the junction of the right atrium/superior vena cava to the skin site, and the catheter was cut to size. A #5 French straight catheter was advanced into the internal jugular vein. The catheter was then placed to flush.
A small skin incision was placed in the upper chest region. Following administration of local anesthesia (1% lidocaine), a tunnel was obtained between the two skin incisions. A vascular sheath was then placed through the tunnel, and the catheter was advanced through the peel-away sheath.

The #5 French straight catheter was then removed under a Rosen wire, and a #10 French peel- away sheath was placed into the right internal jugular vein. The dilator and wire were then removed, and the end of the peel-away sheath was crimped to avoid blood loss with the patient holding his breath. The tip of the catheter was then advanced through the peel-away sheath with the tip of the junction of the right atrium/superior vena cava. The peel-away sheath was then removed and the catheter was adjusted to obtain a smooth transition. The cuff of the catheter was approximately 1 to 2 cm from the incision site. A single 2-0 Prolene suture was then placed at the catheter insertion site, and three sutures were placed at the lower neck incision site. There was no evidence of bleeding.

Contrast was infused through the single port, which revealed adequate placement.

Post placement chest x-ray did not reveal a pneumothorax.

The patient tolerated the procedure well. The patient denied pain and shortness of breath at termination of the study.

IMPRESSION: Placement of a tunneled #14.5 French hemodialysis catheter through the right internal jugular vein as described above.

CPT Code(s):________________________________
ICD-10-CM Code(s): __________________________

Abstracting Questions:
1. Was the catheter inserted by the radiologist?
2. Was the catheter inserted into the venous or arterial system?
3. Was the catheter inserted centrally or peripherally?
4. Was the catheter tunneled?
5. Was a subcutaneous port/pump inserted?
6. Does the age of the patient affect CPT code assignment?
7. Is ultrasound guidance separately reported?

 

SCIENCE
HEALTH SCIENCE
NURSING
CMA – HIMBC MED 107

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