This is a coding case for an Outpatient Surgery case for Digestive System.

Question This is a coding case for an Outpatient Surgery case for Digestive System. There are Please review the documentation of the patient encounter and code the case.7 diagnoses codes (ICD-10-CM) and 4 procedure codes(CPT) CHIEF COMPLAINT: S/p OHT for IDCM with mild transplant vasculopathy by angiography  HISTORY OF PRESENT ILLNESS: is a 9 year old who presents to the cardiac catheterization laboratory for full heart cath to evaluate hemodynamics, coronary arteries with IVUS, angiography and CFR and possible biopsy. Allergies•Measles, Mumps & Rubella Vac Contraindicated with heart transplant immunosuppression •Nsaids Contraindicated with heart transplant immunosuppression •Varicella Virus Vaccine Live Contraindicated with heart transplant immunosuppression History and Physical •Preterm infant about 32 weeks •Iron deficiency anemia •Dilated Cardiomyopathy •Feeding difficulties and mismanagement •Coronary artery disease of transplanted heart DATA/DIAGNOSTIC STUDIES: Echo, ECG, labs ASSESSMENT:  a 9 year old with a history of Dilated Cardiomyopathy: Idiopathic. was transplanted on and is now 5 yrs 9 mths S/P cardiac transplant with mild transplant vasculopathy is doing well and entering 3rd grade. Father continues to have difficulty with language barrier and arranging appointments; attempted to help with arranging dental follow up. Also discussed with father changes to Neoral dosing based on slightly low levels. All discussions and consent were performed with Cyracom vietnamese interpreter via phone. Father did not have further questions or concerns. Father did not know how to use sunscreen and doesn’t like playing outside unless she is in the shade. Encouraged light long sleeves, hat or sunscreen. Father verbalized understanding. PLAN: To cardiac catheterization laboratory for Right and left heart catheterization, Angiography, Endomyocardial biopsy, IVUS, Coronary Flow wire Time Spent/LOS Inpt: I personally spent a total of 45 minutes on the unit in direct management/discussion/coordination of care. Of that, 40 minutes was spent in counseling and/or coordination of care including: counseling patient/family regarding diagnosis, prognosis, and treatment plan (including risks and benefits)     Health Science Science Nursing HCMT 2025C Share QuestionEmailCopy link Comments (0)