Question

CHAPTER 6: CARDIOVASCULAR SYSTEM Case 6-2 LOCATION: Inpatient, Hospital PATIENT: Tim Luther ATTENDING/ADMIT PHYSICIAN: Frank Gaul, MD SURGEON: David Barton, MD PREOPERATIVE DIAGNOSIS: Fluid overload state, no urine output, acute renal failure. POSTOPERATIVE DIAGNOSIS: Fluid overload state, no urine output, acute renal failure. PROCEDURE PERFORMED: Temporary dialysis catheter placement. PROCEDURE: This 77-year-old patient was brought to the emergency room. The right femoral vein was selected. This was tried with the left IJ vein earlier without success. I reserved the right IJ for a central line that will be placed by interventional radiology in the morning. The right femoral vein was localized using ultrasound. (The ultrasound is not a reportable service.) The area was prepped in the usual fashion. One-percent lidocaine was used for local anesthesia. The right femoral vein was accessed under real-time ultrasound guidance without difficulty. The guidewire was advanced smoothly. The hook needle was taken out. The right femoral vein was dilated. An 11.5 French 16-cm temporary dialysis catheter with a straight extension was advanced to the iliac vein through the right femoral vein over the guidewire using the Seldinger technique without difficulty. Both ports had good venous blood return. Both ports were flushed with saline and heparin. The catheter was secured to the skin. The patient tolerated the procedure very well without immediate complication. Dialysis will be done semi-urgently.

Abstracting Questions:

1. What is the name in main term and sub term of the procedure or service provided?

2. What is the name, in main term and sub term of the diagnosis?

3. What is the service code(s) (Please provide CPT codes and ensure the definitions of the codes such as the main term, and the sub terms as listed above match the CPT manual.) Also please explain the rationale of how you coded the service code based on the coding guidelines. What does the guidelines state? What are the page numbers?)

4. What is the ICD-10-CM Code(s): (Please provide the ICD-10-CM codes and ensure the definitions as listed above in #2 match the main terms and sub terms. Also please explain the rationale of how you coded the ICD-10-CM codes based on the coding guidelines. What does the guidelines state? What are the page numbers?)

5. What is another name for a catheter or central line?

6. What vessel was used for the access point for the catheter?

7. Was the insertion central or peripheral?

8. Was the catheter tunneled or non-tunneled?

9. Does the age of the patient affect code selection?

10. Was a port and/or pump inserted?

11. Does the type of radiologic guidance affect the radiology code selection?

Answer 1

1. The main term dialysis and sub term of the procedure provided is temporary dialysis catheter placement

2. The main term of diagnosis is acute renal failure and sub term of the diagnosis is fluid overload

3. CPT code is the current procedural terminology . The CPT code for temporary dialysis catheter placement is 36620 and dialysis is 90935

4. ICD -10-CM CODE is the tenth version of international classification of disease . It is used to code a diagnosis or disease. ICD -10-CM CODE for Acute renal failure is N17.9 and fluid overload is E87.7