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Coding Esophageal Function Testing

Kimberly Posted Thu 17th of April, 2014 10:20:26 AM

Is it correct to code the following report 91010, 91037?

Esophageal Function Test Report
Patient History
Symptom(s): Patient reports dysphagia to solids (occasionally liquids per her husband). Husband also states that she will “pass out” a couple of times a week when she has solid food sticking. They both state that it will depend upon what she eats as to how often she will have dysphagia. She has no heartburn or chest pain. She does have frequent hiccups.
Medications: 20mg omeprazole
Findings
1. LES:
a. Total length = 4cm (normal >3cm)
b. Intra-abdominal length = 1 cm (normal >1cm)
c. Resting LES Pressure = 64mmHg (normal 10-45mmHg)
d. Average Residual Pressure with swallows = 14mmhg (normal <8mmHg)
2. Body of Esophagus :
a. Average Smooth Muscle Amplitude with swallows = 120mmHg/4.5 seconds and 131mmHg/6.4 seconds (normal 30-220mmHg/1-6seconds)
b. Peristalsis = 100% (normal >80%)
3. Bolus Transit :
a. Liquid Bolus Transit = 100% (normal > 80%)
b. Viscous Bolus Transit = 90% (normal > 70%)
Impressions
Normal Esophageal manometry with mildly elevated LES resting pressure and mildly elevated residual pressure (this is with both conventional and Chicago Classification data). Both Liquid and Viscous Bolus transit are normal.
UNI-ESO-WG1A1 - HRZ: EFT 32P/16Z Procedure
LES Profile Data
Proximal: 40.0 cm
Distal: 44.0 cm
Total LES Length: 4.0 cm
PIP: 43.0 cm
Intra-abdominal LES Length: 1.0 cm
LESP Data
Circumferential Sensors
Measured Normal
LESP (Mid Resp): 64.2 mmHg 10.0 - 45.0 mmHg
*If LESP is measured in more than one channel, the maximum value is reported.
LES Relaxations (Liquid)
Number of measurements: 10
Measured Normal
Residual Pressure: 13.8 mmHg < 8.0 mmHg
*Calculated results reflect an average of all measured relaxations.
Swallow Bolus Transit Data (Liquid)
Number of measurements: 10
Complete Bolus Transit: 100 % (10/ 10) > 79 %
MII summary results are means of complete bolus transit swallows:
Swallow Bolus Transit Data (Viscous)
Number of measurements: 10
Complete Bolus Transit: 90 % (9/ 10) > 69 %
MII summary results are means of complete bolus transit swallows:
Swallow Manometry Data (Liquid)
Number of measurements: 10
Proximal Esophagus: Channel 27 at 24.0 cm Normal
Amplitude: 25 mmHg (6 swallows) 30 - 220 mmHg
Duration: 1.0 sec (6 swallows) 1.0 - 6.0 sec
Mid 1 Esophagus: Channel 30 at 28.0 cm Normal
Amplitude: 119 mmHg (10 swallows) 30 - 220 mmHg
Duration: 3.8 sec (10 swallows) 1.0 - 6.0 sec
Mid 2 Esophagus: Channel 34 at 33.0 cm Normal
Amplitude: 120 mmHg (10 swallows) 30 - 220 mmHg
Duration: 4.5 sec (10 swallows) 1.0 - 6.0 sec
Distal Esophagus: Channel 38 at 38.0 cm Normal
Amplitude: 131 mmHg (10 swallows) 30 - 220 mmHg
Duration: 6.4 sec (10 swallows) 1.0 - 6.0 sec
Distal Esophageal Amplitude: 125 mmHg
Onset Velocity Normal
Velocity: 2.9 cm/sec (10 swallows) < 8.0 cm/sec
Peristaltic contractions: 100 % (10/10) > 80 %
Velocities are calculated from the two most distal analysis channels.

SuperCoder Answered Mon 21st of April, 2014 08:01:29 AM

Since pressure measurements and bolus transit are both measured, you can report 91010 and 91037 for this scenario.

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