Billings Community Education Online Medical Classes | Advanced Medical Coding Chapter 6
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Advanced Medical Coding Chapter 6

06 Aug Advanced Medical Coding Chapter 6

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Advanced Medical Coding Chapter 6
Question 1 of 10
An established patient presents to the cardiologist's office for a follow-up visit.
LOCATION: Outpatient, Clinic
PATIENT: Bernie Lieberwitz
PHYSICIAN: David Barton, MD

he patient is here for a follow-up visit. He is an established patient with atherosclerotic heart disease, status post atherectomy of the right coronary artery in 1997. He has done very well over the years. Over the past few months, he has not been feeling as well as he used to in the past. He has been getting some exertional chest discomfort that is short lasting. He also is not having as much exercise tolerance as he used to in the past. He had a Cardiolite stress test done in December of last year, where he exercised for 10 minutes and 30 seconds and achieved 103% of his maximal predicted heart rate. The test was negative for ischemia by electrocardiographic criteria. However, unfortunately there was perfusion defect seen within the posterior/inferior wall of the left ventricle, which was predominantly fixed. That was definitely a change when compared to his previous four Cardiolite stress tests.

Lipitor 20 mg (milligram) q.d. (every day).
Procardia XL 60 mg daily.
Niacin 2 g (gram) daily.
Zantac 150 mg b.i.d. (twice a day).

PHYSICAL EXAMINATION: Blood pressure is 110/80. Pulse is 84. Head is normocephalic and atraumatic. Neck is supple without JVD (jugular vein distention) or bruit. Lungs are clear to auscultation and percussion. Heart is regular; S1 (first heart sound) and S2 (second heart sound); no S3 (third heart sound) or S4 (fourth heart sound). No clicks, rubs, or murmurs. Abdomen is soft and nontender. Bowel sounds are well heard. Extremities, upper and lower: No edema, cyanosis, or clubbing. CNS (central nervous system): Within normal limits. The patient is alert and oriented to time, place, and person.
ASSESSMENT: This is a patient with known atherosclerotic heart disease as described above. Clinically, he has not felt as well as he has in the past. His pain is somewhat atypical. It is concerning that his Cardiolite stress test now for the first time is showing a defect and this is a new finding since 1997. It is of concern and suggests that perhaps he may have occluded or stenosed his right coronary artery.
RECOMMENDATIONS: We talked about options. These were primarily to try to optimize his medical treatment versus repeat cardiac catheterization and coronary angiography. The patient absolutely would like to go with an angiogram and would like it to be done as soon as possible. The procedure and all the involved risks, as well as the treatment alternatives, were fully explained to him. He would like to proceed.

SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________


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