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Medical Coding Reimbursement Assignment Paper

Medical Coding Reimbursement Assignment Paper Medical Coding Reimbursement Assignment PaperCase 1PROCEDURES PERFORMED:  Coronary AngiographyPROCEDURE:Informed consent was obtained from the patient, and a time-out wasperformed to verify the patient’s identification and planned procedure.After the Allen’s test was used to confirm patency of the ipsilateralulnar artery, the patient’s right radial artery site was prepped anddraped in sterile fashion, and anesthetized with 1% subcutaneous lidocaineusing a 25 gauge needle.  The radial artery was then entered bythrough-and-through puncture with a 22G angiocath needle.  The needle wasthen removed, followed by slow withdrawal of the angiocatheter until bloodreturn was seen, confirming intra-arterial position.  A sheath kit wirewas then advanced, allowing for exchange of the angiocatheter for a 5-Frhydrophilic sheath.  The sheath was then flushed with 2.5 mg of verapamildiluted in blood, followed by 50 units/kg (up to maximum of 5000 units) ofheparin administered intravenously.  A 180 cm Radial Glide Wire (1.5 mm J)or Versicore wire was used for initial catheter advancement, and a 260 cm0.035″ J-wire was used for subsequent catheter removal.  Standardangiography was performed using 5 Fr JR4 diagnostic catheters to engagethe left main (LM) and right coronary artery (RCA), respectively. Medical Coding Reimbursement Assignment PaperORDER A PLAGIARISM-FREE PAPER HEREAfter the catheter was removed over the J-wire, the existing sheath waswithdrawn half-way out in preparation for removal.  A VascBand waspositioned as appropriate, and 12 cc of air used to inflate the bandduring simultaneous complete removal of the sheath.  The amount of air wasthen adjusted as need to ensure hemostasis while ideally allowing patencyof the radial artery as confirmed by pulse oximetry during transientipsilateral ulnar artery occlusion.  No immediate complications.  Estimateblood loss: minimal.  Specimens: none.Medical Coding Reimbursement Assignment PaperI reviewed the patient’s pre-sedation assessment and vital signs,supervised and directed the moderate sedation with continuous face-to-faceattendance.  My intra-service time was 38 min.  Please see procedure logor sedation record for more details.Case 2PROCEDURE:Right internal jugular vein tunneled hemodialysis catheter placement.PRE-PROCEDURE DIAGNOSIS:End-stage renal disease. Patient needs long term central venous access for hemodialysis.SEDATION:I was personally responsible for the administration of moderate sedation services during the procedure performed.  Iconfirm all of the requirements of moderate sedation were followed.  This included the use of an independent trainednurse who had no other duties during the procedure.  The drugs utilized were midazolam and fentanyl.  Continuousmonitoring and face-to-face time began at 1707 hours and ended at 1747 hours.  Total minutes and further documentationcan be found in the nursing/procedure log for this encounter date of service.TECHNIQUE:After application of 1% lidocaine for local anesthesia, the right internal jugular vein was accessed with amicropuncture system with real-time ultrasound visualization of vascular needle entry and permanent image recording. Aguidewire was advanced under fluoroscopic guidance. A short incision was made in the infraclavicular region.  Asubcutaneous tunnel was made to the venotomy site, through which the catheter was placed. The venotomy was dilated toaccept the peel-away sheath, through which the leading end of the 14.5-French, 23 cm HemoStar dialysis catheter wasadvanced under fluoroscopic guidance.  Catheter tip positioned in the mid right atrium. The venotomy incision was closedwith absorbable suture and skin adhesive, and the catheter was secured to the skin with suture.Medical Coding Reimbursement Assignment PaperThere was good flush and aspiration through both catheter lumens.  All lumens were flushed with heparin solution.Post-placement radiograph was obtained. A sterile dry dressing was placed over the catheter exit site. The procedure waswell-tolerated without immediate complications.MEDICATIONS:Midazolam 0.5 mg IVFentanyl 25 mcg IVLidocaine 1% subcutaneousRADIATION DOSE: Air Kerma 12.7 mGyFLUOROSCOPIC TIME: 0.8 minutes.ESTIMATED BLOOD LOSS: NoneSPECIMENS OBTAINED: None.COMPLICATIONS: None.FINDINGS:1. Ultrasound demonstrates a patent right internal jugular vein.2. Post-placement radiograph shows an appropriately positioned tunneled catheter with the tip at the right atrium.Impression:IMPRESSION:Successful placement of tunneled right internal jugular hemodialysis catheter (14.5-French, 23 cm HemoStar dialysiscatheter). The catheter is ready for immediate use. Medical Coding Reimbursement Assignment PaperCase 3Procedure: Dual Chamber Implantable Cardioverter Defibrillator (ICD) ImplantationPre-Procedure Diagnosis: Hypertrophic Cardiomyopathy, NSVT, SSS, Near SyncopeProcedure: The patient was brought to the Electrophysiology Lab in thefasting state and continuous electrocardiographic monitoring wasinstituted.Anesthesia was performed by Dr Kiss and will be dictated separately byhim.The left subclavicular fossa was prepped and draped in the usual sterilefashion and 1% lidocaine was instilled for local anesthesia.  The incisionwas made and the dissection was carried down to the level of thepectoralis major fascia where a subcutaneous pocket was formed using bluntdissection.  The axillary vein was entered with a Micropuncture thinwalled needle without difficulty at two separate locations, guided byultrasound, and guide wires were advanced into the central venouscirculation. Using the guide wires and two introducer sheaths, an ICDelectrode was advanced to the right ventricular septum, and a pacingelectrode was advanced to the right atrial appendage under fluoroscopicguidance. Each electrode was anchored to the underlying pectoralis majorfascia with a single stitch of 2-0 non-absorbable suture.These leads were attached to a dual chamber ICD which was placed in thepreviously formed pocket with electrodes situated beneath it after thepocket had been flushed with saline solution.The ventricular electrode is a Medtronic Model # 6935M62 (Serial #TDL515430V).  This is a bipolar, steroid-tipped, active fixation lead.The R wave was 10 mV, the pacing impedance was 600 Ohms, and theventricular capture threshold was 0.75 V @ 0.5 ms.  The HVB impedance was76.  There was no diaphragmatic pacing at 10 V. Medical Coding Reimbursement Assignment PaperThe atrial electrode is a Medtronic Model # 5076 (Serial # PJN8450680).This is a bipolar, steroid-tipped, active fixation lead.  The P wave was1.3 mV, the pacing impedance was 650 Ohms, and the atrial capturethreshold was 1.3 V @ 0.5 ms.  There was no diaphragmatic pacing at 10 V. Medical Coding Reimbursement Assignment PaperThe ICD pulse generator is a Medtronic Evera MRI DR.  Model # DDMB1D4,Serial # PFZ622773S.  This device is placed in the subcutaneous location.No defibrillation threshold testing was performed.The wound was closed with a running stitch of 3-O absorbable suture andthe skin was closed with a running stitch of 4-O absorbable suture.Topical skin adhesive was placed over the incision.The patient tolerated the procedure well. Medical Coding Reimbursement Assignment Paper

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