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Chapter 18
ASSIGNMENT 18.2 – C.ODING MEDICINE REPORTS
Instructions
Assign the ICD-10-CM code(s) to diagnoses and conditions and assign the CPT medicine code(s) and the
appropriate HCPCS level II and CPT modifier(s). Do not assign ICD-10-CM external cause codes.
1. CAROTID ULTRASOUND
DIAGNOSIS: Screening exam, risk factors for cardiovascular disease.
Multiple real-time images were made of both carotid arteries from the supraclavicular area to the bifurcation.
The common carotid arteries are of normal caliber bilaterally with no evidence of any plaque formation or
stenosis. The bifurcations are well demonstrated bilaterally and are normal. There is a very tiny calcified
plaque involving the posterior wall of the left carotid artery just proximal to the bifurcation. This is only
about 2 mm in size, and I do not think it is significant.
CONCLUSION: Normal carotid ultrasound.
2. ELECTROENCEPHALOGRAM (EEG)
COMPLAINT: Seizure.
CURRENT MEDICATIONS: Phenobarbital, Theo-Dur, Peri-Colace.
STATE OF PATIENT DURING RECORDING: Awake.
DESCRIPTION OF EEG: The background is not well developed. Much muscle tension artifact is
superimposed; electrode artifact also present at times. No spike-wave discharges, paroxysmal slowing, or
focal abnormality present. Hyperventilation procedure was not done. Sleep did not occur. Total recording
time was 35 minutes.