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Amazing tips to Perfectly code a Medical report

In radiology coding, we usually come across CT,CTAMRI, X-ray reports etc. charts which are very common in this facility.  Radiology coding is not difficult if you know how to read and code a medical report. Yes, we don’t have to take any training or clear any CPC certification exam to be a radiology coder. If you know how to the ICD coding guidelines and how to search a code in codebooks, then you can easily become a coder. Yes, It is also important to  grow in medical coding profession, so one should always have a credential like CPC-A,CPC, COC, CIC, CCS etc. for having a successful career in medical coding. 

Amazing tips to Perfectly code a Medical report

How to code sample Medical report

Since ICD 10 codes(Z codes) have replaced ICD 9 codes (V codes), we have to now follow only ICD 10 codes. Since, there is a lot of difference between ICD 9 and ICD 10 codes we have to be very careful with diagnosis coding. For example, the new ICD 10 codes for injuries for initial, subsequent encounter or sequela are still causing confusion. While Z3A category codes should not be forgot to be used along with pregnancy complication ICD 10 codes. Do try to avoid these common mistakes while coding ICD 1o codes.

For CPT codes in radiology, we have to just focus on the documentation of medical report. You can easily search CPT codes, if you know the procedure performed in the report. Now, below I have shared sample radiology report. Now, with the exam heading it says “CT Chest, Abdomen and Pelvis with contrast“. Now, if we separate this exam we can say they have performed “CT chest with contrast” and “CT abdomen & Pelvis with contrast“. We have a combine CT code for abdomen and pelvis. Now, if you come down the report, you can see the technique. The technique gives more information about the exam like name of the contrast and quantity of the contrast used for the exam. Do remember in radiology only intravenous contrast is considered as “with contrast” while coding procedure code. Oral contrast are always considered “without contrast” in radiology coding. Now, once we have verified the exam with technique, we can come to the conclusion and code the correct CPT code. So, you can see the final CPT codes for the below sample report is

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71260- CT chest with IV contrast

74177- CT abdomen and pelvis with IV contrast

CT/CT CHEST-ABD-PELV W/IV CM

CLINICAL DATA: Follow-up metastatic right breast cancer, lung metastases, chemotherapy complete March 2015, status post XRT in 2009.

EXAM: CT CHEST, ABDOMEN, AND PELVIS WITH CONTRAST

TECHNIQUE: Multidetector CT imaging of the chest, abdomen and pelvis was performed following the standard protocol during bolus administration of intravenous contrast. 

CONTRAST: 100 mL Isovue 370 IV

FINDINGS:

CT CHEST FINDINGS

Mediastinum/Nodes: The heart is normal in size. No pericardial effusion. Atherosclerotic calcifications of the aortic root/arch.Right chest port terminates at the cavoatrial junction. No suspicious mediastinal, hilar, or axillary lymphadenopathy. Status post right axillary lymph node dissection.Lungs/Pleura: Clustered nodularity in the right lower lobe , new, possibly infectious. 6 mm right lower lobe pulmonary nodule , new, worrisome for metastasis. Additional scattered nodularity in the bilateral lungs, including a 3 x 4 mm nodule in the left lower lobe, more conspicuous than on prior studies, nonspecific. No pleural effusion or pneumothorax.

Musculoskeletal: Status post right lumpectomy.

Degenerative changes of the thoracic spine.

CT ABDOMEN PELVIS FINDINGS

Hepatobiliary: Liver is within normal limits. Gallbladder is underdistended. No intrahepatic or extrahepatic ductal dilatation. Pancreas: Within normal limits. Spleen: Within normal limits. Adrenals/Urinary Tract: Adrenal glands are within normal limits. Kidneys are within normal limits. No hydronephrosis. Bladder is within normal limits. 

Stomach/Bowel: Postsurgical changes related to gastric bypass.

Patent gastrojejunostomy. No evidence of bowel obstruction. Normal appendix.

Vascular/Lymphatic: Atherosclerotic calcifications of the abdominal aorta and branch vessels.

No suspicious abdominopelvic lymphadenopathy.

Reproductive: Uterus is within normal limits. No adnexal masses.

Other: No abdominopelvic ascites.

Musculoskeletal: Degenerative changes of the lumbar spine.

IMPRESSION: Status post right lumpectomy with right axillary lymph node dissection.

6 mm right lower lobe pulmonary nodule, new, worrisome for metastasis. Additional scattered nodularity in the bilateral lungs, more conspicuous than on prior studies, nonspecific. Clustered nodularity in the right lower lobe, possibly infectious. No evidence of metastatic disease in the abdomen/pelvis

CPT codes: 74177, 71260

 

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Understanding Medical Coding: A Comprehensive Guide CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association
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