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PATIENT: Joanne Stewart ORDERING PROVIDER: Susan Alameda, DО СТА АВDOMEN AND PELVIS WO/W CONTRAST: Findings: The heart size is within normal limits. No pleural or pericardial effusions. Mild calcified atherosclerotic disease of the coronary arteries. Minimal atelectasis at the lung bases. There is a 6.5-cm lesion in the right lobe of the liver with peripheral puddling of contrast, which is most consistent with a giant hemangioma. There is no biliary ductal dilatation. The pancreas, spleen, and adrenal glands are normal in appearance. Mild cortical scarring of the kidneys. There is a 2-cm cyst in the upper pole of the left kidney. No pathologically enlarged lymphadenopathy. The urinary bladder is within normal limits. Normal uterus and ovaries. No free fluid in the pelvis. Mild fecal retention. No focal bowel wall thickening. Normal appendix. Normal small bowel. Vasculature: There is 30-40% narrowing of the celiac axis based on NASCET criteria. Minimal poststenotic dilatation. There has been interval placement of a stent in the proximal SMA with significant improvement of flow. No definitive evidence of in-stent stenosis, although the stent is of small caliber. Mild narrowing of the right proximal renal artery. There is a 40-50% stenosis at the origin of the left renal artery. 50% stenosis of the IMA. Moderate atherosclerotic disease of the distal abdominal aorta. There are kissing bilateral iliac stents. Moderate atherosclerotic disease of the internal iliac arteries. Mild atherosclerotic disease of the external iliac arteries. Moderate disease of the common femoral arteries bilaterally. The profunda femoral arteries are mildly to moderately diseased. Normal alignment of the lumbosacral spine with osteopenia. There is mild compression deformity of T12. Multilevel degenerative disease. IMPRESSION: 1. Interval placement of a stent in the origin of the SMA with significant improvement of flow. No definitive evidence of in-stent stenosis. 2. 30-40% stenosis of the origin of the celiac axis 3.40-50% stenosis at the origin of the left main renal artery 4. 50% stenosis of the origin of the IMA 5. Kissing common iliac stents with moderate atherosclerotic disease 6. Giant hemangioma in the right lobe of the liver 7. Mild chronic compression deformity of the T12 vertebral body 8. 2-cm left renal cyst Percentages stenosis were obtained using NASCET technique of stenosis calculation. SIGNED: Dr. Gene I. Kim, MD Select the appropriate codes for the case study. 1. List the ICD-10-CM codes: 2. List the CPT/HCPCS code and any applicable modifiers: 3. List the procedure and diagnosis codes on the CMS-1500 form. Be sure to correctly link the procedure and diagnosis codes.

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