CASE 9-6 Pulmonary Function Study You will be reporting only the physician portion of the service. I. Question
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CASE 9-6
Pulmonary Function Study
You will be reporting only the physician portion of the service. In this case, the diagnoses that you are to report have been highlighted. The five reportable services of this study are indicated for you by the name of the study having been placed after each element in the Interpretation section of the report. Note that the components of the spirometry are not indicated in consecutive order in this report and often are not in order; rather, items 1, 2, 7, 8, and 9 are all parts of the spirometry. You will be coding another pulmonary function study in Case 9-9A without any indicators, so study this report carefully to ensure that you can identify the various elements of the study without the indicators.
LOCATION: Outpatient, Clinic
PATIENT: Hag Ulrich
PHYSICIAN: Gregory Dawson, MD
ENTRANCE DIAGNOSIS: Dyspnea in a patient who has a 67.5-packs-per-year history of smoking and has a nonproductive cough. Gave good consistent effort.
INTERPRETATION:
1. Flow volume loop has mild concavity toward the volume axis, well-preserved inspiratory limb, reduced flow rates. (spirometry)
2. No significant change after bronchodilator. (spirometry)
3. Lung volumes are normal without evidence of hyperinflation. (also known as functional residual capacity)
4. Single-breath lung volumes are also normal without hyperinflation. (functional residual capacity)
5. There is significant dynamic airway collapse. (gas volume)
6. Transfer factor is reduced to 52% of predicted, suggesting reduced alveolar capillary membrane surface area and/or V/Q mismatching. (carbon monoxide, diffusion capacity)
7. Prebronchodilator flow rates have a pattern consistent with mild chronic obstructive pulmonary disease. (spirometry)
8. Postbronchodilator values show no significant change, and the same conclusion can be reached. (spirometry)
9. The MVV (maximum voluntary ventilation) is abnormal prebronchodilator and postbronchodilator. Between that and a normal FEV1 (forced expiratory volume in one second), I expect a reasonably normal exercise tolerance. (spirometry)
10. Airway resistance is normal. (resistance to airflow)
OVERALL IMPRESSION: COPD (chronic obstructive pulmonary disease) of mild degree; no significant reversibility. It does not explain this patient’s complaint of being short of breath after any exertion, and it would probably be reasonable to get a methacholine challenge after the patient quits smoking to see whether he has bronchospastic disorder. One can assume that kind of complaint with his smoking history and that he probably already does have a bronchospastic component.
CPT CODE(S): ________________________________________
ICD-10-CM DX CODE(S): ____________________________________
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CASE 9-6 Pulmonary Function Study You will be reporting only the physician portion of the service. I
