# Code A round help needed



## jgryder@rocketmail.com (May 12, 2011)

Can someone help me please?   I am completely stumped by this note.  I have gotten the others - but this one is nailing me.

REASON FOR CONSULTATION: History of coronary artery disease. HISTORY OF PRESENT ILLNESS:  Patient is a pleasant 93-year-old gentleman with a history of ischemic cardiomyopathy. He has had coronary artery bypass grafting, I believe in1993 as well as1999, has an ejection fraction between 20 and 30%. Recently, he underwent a pacemaker generator change without complications. He presented to the emergency room earlier today with complaint of lower back pain. He was found to be significantly hypotensive in the emergency room, was also found to be significantly anemic with hemoglobin of 8.7. In addition, he has progressive renal insufficiency with BUN and creatinine this admission of 91 and 3.5 respectively. Currently, he is resting comfortably having received packed red cell transfusion. His blood pressure is improved. Currently, his cardiac medications are being withheld both because of his blood pressure and his renal insufficiency. He denies any orthopnea, PND or edema. At this time, he has also had no recent chest pain and denies any recent history of syncope, presyncope, or palpitations. PAST MEDICAL HISTORY: 1. Coronary artery disease. The patient underwent bypass grafting in 1993 and 1999 and has had aortic valve replacement as well. 2. Ischemic cardiomyopathy, EF 20-30%. 3. Status post pacemaker. 4. Gout. 5. History of transient ischemic attack. 6. Macular degeneration. 7. Benign prostatic hypertrophy. 8. Hypertension. 9. Dyslipidemia. 10. History of cataracts. 11. Chronic kidney disease. There is no history of diabetes. SOCIAL HISTORY: Negative for cigarette smoking or alcohol. MEDICATIONS ON ADMISSION: Lasix, Coreg, Lisinopril, Xalatan, Simvastatin, Aldactone, Omeprazole, supplemental Ocuvite and Procrit. REVIEW OF SYSTEMS: CONSTITUTIONAL: No recent change in weight. No recent fevers, no sweats. EYES: No recent loss of vision or double vision. ENT: No recent URI symptoms, difficulty swallowing or neck pain. RESPIRATORY: No recent cough, hemoptysis or sputum production. CARDIAC: As above. GASTROINTESTINAL: No recent abdominal pain, hematemesis or blood per rectum. GENITOURINARY: No recent hematuria or dysuria. SKIN: No recent rashes or lesions. MUSCULOSKELETAL: No recent joint pains or swellings. NEUROLOGICAL: No recent loss of motor or sensory neurological function. No change in speech or history of seizure disorder. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 106/48, heart rate 67, respiratory rate is 18, saturation 100% on room air, and temperature is 96.7 degrees. GENERAL: Elderly male in no acute distress. EYES: Pupils equal, round and reactive. Extraocular movements intact. ENT: Oral mucosa normal. NECK: Supple. There is no jugular venous distention noted. No carotid bruits. LUNGS: Clear in the mid and upper fields bilaterally. There is perhaps decreased sound slightly in the right base. CARDIAC: PMI is laterally displaced in the fifth interspace. Rhythm is regular with ectopy noted. S1 and S2 are heard. No 3 is noted today, 1/6 systolic murmur left lower sternal border. No diastolic murmurs or rubs are noted. Carotid, radial and femoral pulses are palpable. ABDOMEN: Soft. Bowel sounds present. No pulsatile mass. SKIN: No rashes or lesions. LYMPHATICS: No cervical or inguinal adenopathy. MUSCULOSKELETAL: No joint tenderness or effusions. No clubbing, cyanosis or edema. NEUROLOGIC: Nonfocal. IMAGING DATA: Electrocardiogram paced rhythm dual-chamber rate 60 beats per minute. Chest x-ray cardiomegaly unchanged small right pleural effusion noted. No infiltrates noted. LABORATORY DATA: White count 5.3, hemoglobin 8.7 and platelets are 187,000. BUN is 91, creatinine 3.5. ASSESSMENT: A 93-year-old gentleman with significant ischemic cardiomyopathy admitted with hypotension, back discomfort, and progressive renal insufficiency. SUGGESTIONS: 1. For the time being, we will need to withhold all of his cardiac medications both because of the renal insufficiency and hypotension. 2. We will reintroduce Carvedilol first when his blood pressure tolerates and then we will reintroduce diuretics and the angiotensin receptor blocker when okay with renal. 3. From cardiac standpoint, the patient does seem to be stable and well compensated from the standpoint of CHF. 4. We will follow along with you. Please call for questions.

__________________

Codes I have used and checked out correct are:

99253
593.9
458.9
414.8

I have tried CAD, TIA, post pacemaker, post cabg, etc., etc., etc.  I tried 93010 for interpretation and report of EKG not performed in clinic

What am I missing?   It will not accept the CAD codes which seem the most logical.   Thanks for any help you can provide.
Janet Gryder, CPC, CCC
Clinic Mgr- Blount Heart


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## sundance5656 (May 12, 2011)

724.2 low back pain. That's all I can think of, sorry.


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## jgryder@rocketmail.com (May 12, 2011)

I tried that as well - as a matter of fact, I even tried generalized pain - just in case.   I tried CHF, CAD, pain, post this and post that - I am completely stumped.  But -  hey thanks for your help and trying!  I appreciate it.


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## OliviaPrice (May 13, 2011)

I get 99253 or 99203 depending on the insurance carrier 
414.8
458.9
724.2 
593.9

Have you tried 425.4 for cardiomyopathy??  

Let us know what you figure out!


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## jgryder@rocketmail.com (May 16, 2011)

Yes - I tried 425.4 plus all of the above codes.  It will not take 724.2 for the back discomfort.   I am at an empasse.  

99253 is correct - it accepts the correct codes and this is what I have - 99253, 593.9, 458.9, 414.8.  I don't know what else to add.    
Thanks for your help!  I appreciate it.
Janet


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## theresa.dix@tennova.com (May 20, 2011)

jgryder@bmnet.com said:


> Yes - I tried 425.4 plus all of the above codes.  It will not take 724.2 for the back discomfort.   I am at an empasse.
> 
> 99253 is correct - it accepts the correct codes and this is what I have - 99253, 593.9, 458.9, 414.8.  I don't know what else to add.
> Thanks for your help!  I appreciate it.
> Janet





Janet,
 try adding 725.5. For back ache unspecified since in the assessment it doesnt say low back pain just back discomfort.


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## jgryder@rocketmail.com (May 20, 2011)

*Code - a - Round - Help*

725.5 doesn't work either.  I've tried everything that I can think of.   Thanks for your  help.  

Any other ideas?


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## carps14 (Nov 27, 2011)

99253
414.8
458.9
724.5
593.9


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