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Original Question

Patient Name: Frank Currier DOB: 06-07-53 Ordering Physician: Grant Sims, MD Gender: M Interpreting Physician: Charles Hanes, MD Date of Service: 07-08-XX Indication: Pulmonary fibrosis, DOE, hypoxemia Exam: Pulmonary Stress Test, 6-minute walk test Findings: The patient ambulated 788 feet. Prior to exercise, no dyspnea with moderate fatigue noted. She had mild dyspnea post-exercise with moderate fatigue. O2 saturation prior to walking was 94% on room air, heart rate 84, respiratory rate 18, and blood pressure 132/80. After 1 minute of walking, her oxygen saturation fell to 83% with a heart rate of 124, and a respiratory rate of 24. She was placed on 2 L of oxygen and she ambulated again. O2 saturation by 4 minutes was 89%, by 6 minutes 90, with a heart rate of 112 and a respiratory rate of 25. Normal recovery. Airflow revealed severe reduction in FVC at 1.17 liters or 45% of predicted. The FEV1 was 1.08 liters or 53% of predicted, FEV1 percent was 92. No significant response to bronchodilator. He had moderate to severe reduction in slow vital capacity at 1.37 liters or 52% predicted. The TLC was 2.53 liters or 59% of predicted. Diffusing capacity was 29% which was severely reduced. Airway resistance was normal. Impression: Severe restriction with diffusion impairment. Compared to previous studies completed last year and the year before, the patient’s total lung capacity is slightly reduced compared to the original study and the FVC is mildly reduced also from the baseline 1.28 liters to 1.17 liters. FEV1 percent is similar. Diffusing capacity is mildly reduced. Pulmonary fibrosis Exercise hypoxia requiring 2L nasal cannula Give the correct CPT and ICD-10 codes.

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