Pediatric and Asthma Management Cases

Study Notes

Case 1: Pediatric Well Check

10-year-old patient presents for a well child check with complaints of frequent urination.
Normal physical examination across all systems; skin showed a 3mm papule on the right hand.
Urinalysis indicates trace blood and low specific gravity; overall results are mostly normal.
Counseling provided on safety measures, including seat belts and gun safety.
CPT® Codes: 99393-25 (preventive exam), 17110 (removal of wart), 90471 (vaccine administration), 90716 (varicella vaccine), 81002 (urinalysis).
ICD-10-CM Codes: Z00.121 (well child check), F90.9 (ADHD), B07.9 (viral wart), R35.0 (frequent urination), Z23 (vaccination).

Case 2: Asthma Management

Diagnosis before and after procedure is asthma; psychophysiological therapy (biofeedback) administered.
Patient showed improvement with fewer asthmatic episodes and reduced inhaled steroid dosage.
Biofeedback utilized HRV monitoring and EEG for assessment during a 28-minute session.
CPT® Code: 90875 (psychological therapy).
ICD-10-CM Code: J45.909 (uncontrolled asthma).

Case 3: Gastro-esophageal Reflux Disease (GERD)

Procedure performed included esophageal pH monitoring using Bravo pH Capsule.
Patient received moderate sedation; capsule placed 5 cm proximal to the lower esophageal sphincter.
Successful placement of the pH capsule confirmed post-procedure; well tolerated.
CPT® Code: 91035 (pH monitoring).
ICD-10-CM Code: K21.9 (GERD).

Case 4: Obstructive Sleep Apnea

Patient underwent an overnight polysomnogram in a sleep lab.
Documented severe obstructive sleep apnea with 80 obstructive apneas in the first 82 minutes of sleep.
CPAP titrated from 5 to 18 cm H2O showed improvement in apnea-hypopnea index from 60 to 4 events/hr.
CPT® Code: 95808 (polysomnography).
ICD-10-CM Code: G47.33 (obstructive sleep apnea).

Case 5: Echocardiogram Findings

Echocardiogram performed indicated borderline left ventricular hypertrophy and mild aortic insufficiency.
Left ventricular ejection fraction recorded at 80%, suggesting good heart function.
CPT® Code: 93306 (echocardiogram).
ICD-10-CM Codes: I51.7 (heart disease), I35.1 (aortic insufficiency).

Case 6: Varicose Vein Disease

Duplex ultrasound performed on lower extremities to evaluate venous anatomy.
Findings include varicose vein disease with inflammation, venous insufficiency, and pain.
Significant findings include absence of great saphenous veins due to prior surgery and venous reflux documented.
CPT® Code: 93970 (ultrasound).
ICD-10-CM Codes: I83.11 (varicose veins), I83.12 (varicose veins with inflammation), I83.813 (varicose veins with pain).

Case 7: Sleep Study Results

Patient underwent an overnight polysomnogram, delivering findings of mild sleep apnea.
Total sleep time was 221 minutes with 256 episodes of arousal noted during sleep.
Average oxygen saturation was 95%, with the lowest being 84%.
CPT® Code: 95810 (polysomnography).
ICD-10-CM Code: G47.30 (sleep apnea).

Case 8: Vagal Nerve Stimulator Analysis

Patient received analysis of vagal nerve stimulator due to history of epilepsy.
Programming and operational status verified, with analysis taking approximately 20 minutes.
CPT® Code: 95970 (nerve stimulation analysis).
ICD-10-CM Codes: G40.909 (epilepsy), Z96.89 (presence of other devices).

Case 9: Photodynamic Therapy for Keratosis

Patient treated with blue light photodynamic therapy for keratosis lesions on the neck.
Procedure included the application of a topical sensitizing agent and blue light therapy for 15 minutes.
Post-procedure skin showed slight redness, with no swelling.
CPT® Code: 96573 (photodynamic therapy).
ICD-10-CM Codes: J7308 (Levulan), L57.0 (actinic keratosis).

Case 10: Abdominal Aorta Ultrasound

Abdominal ultrasound identified an aortic mass, measuring 4.8 cm in anteroposterior diameter.
Findings communicated to the attending physician for further assessment.
CPT® Code: 93979-26 (ultrasound).
ICD-10-CM Code: I71.4 (abdominal aortic aneurysm).

Description

Explore two clinical cases focusing on a pediatric well child check and asthma management. The first case involves a 10-year-old with frequent urination and a normal exam, while the second case highlights the use of biofeedback therapy for improving asthma symptoms. Test your knowledge of common diagnoses, treatments, and coding in these scenarios.