( I Have the answers (the codes at the bottom) provided. I just need somebody to tell me step by step on how they got those codes using their medical coding textbooks)
CASE 8Location: Regional HospitalEXAM:Renal and bladder ultrasound dated 10/01/20XXRenal artery Doppler evaluation dated 10/01/20XXCOMPARISON:Renal MRA dated 04/01/20XXHISTORY:80-year-old with renal artery stenosis. Diagnostic ultrasound of the kidneys was ordered to see if there was kidney damage due to the renal stenosis or other kidney issues. This was followed after review with a renal Doppler study.FINDINGS:Multiple grayscale sonographic and color Doppler images of the kidneys and renal vasculature were submitted for interpretation.The right kidney measures 10.1 cm without evidence of pelvic caliectasis.There is a small 8mm cyst noted within the lower pole of the right kidney. There is relatively normal internal architecture and echogenicity. The left kidney measures 10.4 cm with no evidence of pelvicaliectasis. There are at least 3 renal cysts identified, the largest measuring 2 cm in diameter. There is normal internal architecture and echogenicity. The bladder is distended with urine and appears within normal limits.The aorta demonstrates peak systolic velocity of 1.07 m/sec.The right renal artery origin demonstrates peak systolic velocity of 3.0 m/sec with a resistive index of 0.92. The midportion of the right renal artery demonstrates a peak systolic velocity of 1.1 m/sec with resistive index of 0.8. The right renal hilum has a peak systolic velocity of 0.64 m/sec with resistive index of 0.85. The inferior pole has a systolic velocity of 0.16 m/sec with resistive index of 0.54. The midpole has a systolic velocity of 0.18 m/sec and resistive index of 0.70.The superior pole has a velocity peak of 0.22 m/sec with a resistive index of 0.77.The left renal artery origin demonstrates a peak systolic velocity of 2.0 m/sec with a resistive index of 0.87. The mid portion of the left renal artery demonstrates a peak velocity at 0.42 m/sec and a resistive index of 0.80. The left renal hilum has a peak systolic velocity of 0.47 m/sec and a resistive index of 0.82. The inferior pole has a systolic velocity of 0 16 m/sec and a resistive index of 0.67. The midpole has a systolic velocity of 0.17 m/sec and a resistive index of 0.63.The superior pole has a velocity peak of 0.13 m/sec with a resistive index of 0.69.IMPRESSION:RENAL ARTERY DOPPLER STUDY:1. Moderate stenosis of the right renal artery origin.2. Mild to moderate left renal artery origin stenosis.RENAL AND BLADDER ULTRASOUND:1. Bilateral probable renal cysts.2. Normal appearing bladderWhat are the CPT and ICD-10-CM codes reported for this service?93976-26, 76770-26-59, I70.1
Expert Solution Preview
To determine the CPT and ICD-10-CM codes for this service, we need to analyze the documentation provided in the case.
CPT code 93976 (with modifier -26) is reported for the renal artery Doppler evaluation. This code includes the evaluation of blood flow in the renal arteries and the calculation of the resistive index.
CPT code 76770 (with modifier -26 and -59) is reported for the renal and bladder ultrasound. This code includes the evaluation of the kidneys, renal vasculature, and bladder using grayscale sonographic and color Doppler images. The -26 modifier indicates that the service was professional component only, and the -59 modifier indicates that the service was distinct from other services performed on the same day.
ICD-10-CM code I70.1 is reported for the diagnosis of moderate stenosis of the right renal artery origin and mild to moderate stenosis of the left renal artery origin. This code identifies the underlying condition for which the services were performed.
Therefore, the CPT and ICD-10-CM codes reported for this service are:
CPT codes: 93976-26, 76770-26-59
ICD-10-CM code: I70.1
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