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A catheter is placed from the femoral artery into the right common carotid, with imaging of the ipsilateral extracranial carotid and bilateral external carotids.
Which CPT® codes are reported?
A 74-year-old arrived at the ED experiencing bright red rectal bleeding when using the toilet. She does not have any abdominal pain, no nausea or vomiting. She has been undergoing dialysis for
years due to end-stage renal failure and has a diagnosis of myelodysplastic syndrome with a platelet count of just 3,000. Her hemoglobin level, which was 10 at her dialysis session the
previous day, dropped to 7. Abdominal films are negative. An urgent esophagogastroduodenoscopy (EGD) was performed, and no active bleeding was found in the esophagus or the stomach.
However, the scope was passed into the upper duodenum which did reveal some oozing, and was controlled with cautery. Next, the patient was then positioned on her left side for a
colonoscopy that extended from the colon to the ileum and into the lower duodenum, but no definitive sources of bleeding were found. Again, no outright bleeding sources were identified. A
CRNA performed the anesthesia and documented PS III.
What CPT® codes are reported for the CRNA?
(Full Case:Preoperative diagnosis:Low back pain; possible spinal stenosis L3–4.Postoperative diagnosis:No evidence of discogenic pathology or spinal stenosis at L3–4; normal discography L3–4.Procedure:Awake discography and injection, L3–4.Anesthesia:IV narcotic with reversal and local; propofol given transiently, then patient alert/responsive for pain response during injection.Technique:Patient to OR; right decubitus; sterile prep/drape; C-arm used to mark entry; local ethyl chloride + 1% Xylocaine; docking needle placed posterolateral at L3–4 under AP/lateral; inner needle advanced to disc nucleus center; contrast injected while monitoring patient response; normal bilocular pattern; 1.5 cc volume; no pain with pressurization.Documentation:No videotape; plain films available; post-discography CT planned/reviewed for other causes.Question:What CPT® and ICD-10-CM coding is reported?)