Question

CHAPTER 2: MEDICINE

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 thanthe digit pressures regarding this area.

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.

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.

5. Does the laser description affect the CPT code selection for the Doppler scan? Please explain.

6. Is CPT code selection affected by type (arterial or venous) of study? Please explain.

7. Does bilateral versus unilateral affect CPT assignment? Please explain

Answer 1

1. The name in main term and sub term of the procedure or service provided is Bilateral laser - Doppler test

2. The name, in main term and sub term of the diagnosis is peripheral angiopathy as a complication of diabetes.

3. The service code of the procedure is 93925 — Duplex scan of lower extremity arteries or arterial bypass grafts, complete bilateral study

4. ICD -10- CM code for peripheral angiopathy due to diabetes is E13.51