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Since, we are here to learn about medical coding, we have to go through the charts as well. The medical coding charts are little difficult to understand in the beginning but once you become in reading the report then their won’t be any problem. Some of the medical coding examples or sample charts i am going to share with you in the article. Just go through the articles and check the CPT and ICD 10 codes assigned to them. If you able to understand these medical coding examples or charts, then you can easily code a medical report. Just try to solve the below examples or sample coding charts with the CPT and ICD codebooks. Hope, you will be able to
Medical coding Examples – 1
This sample medical report is about coding Abscess procedures. This report is a very good example to learn about interventional radiology CPT codes. If you are able to code this sample report, you will able to understand about how to read and code a medical report. Now, just try to first code the below sample medical report and check the correct codes later. This way you can improve you skills in medical coding.
CT GUIDED DRAIN ABSCESS
PROCEDURE: CT GUIDED RETROPERITONEAL PERIPANCREATIC FLUID COLLECTION DRAINAGE
INDICATIONS: Status post bowel resection. History of pancreatic cancer and metastatic disease. The patient has persistent leukocytosis. CT imaging demonstrates a rim-enhancing mass concerning for abscess.
MEDICATIONS: See nursing MAR. Moderate sedation was monitored by the Radiology nursing team.
PROCEDURE: Written informed consent was obtained in a SPARQ conference with the patient. The patient was prepped and draped in the usual manner. Using local anesthetic and non-contrast enhanced CT guidance a blunt tipped Hawkins needle was advanced into the fluid collection from a posterolateral retroperitoneal approach. Purulent fluid was aspirated and sent to the laboratory for further evaluation. Over a guidewire serial dilatation was performed and a 10 French multipurpose drainage catheter was advanced into the collection using CT guidance. The catheter was aspirated and placed to suction bag drainage. The catheter was sutured in place. A completion CT was obtained.
FINDINGS: There is a fluid collection in the peripancreatic retroperitoneum. A total of 40 mL of purulent fluid was aspirated. A 10 French drainage catheter was positioned in the collection.
IMPRESSION: Successful CT guided drainage of retroperitoneal peripancreatic fluid collection with removal of 40 mL of purulent fluid.
CPT: 49406-59, 49405
Medical coding Examples – 2
Below sample report is again a very good example for medical coders. If you have good coding knowledge about ultrasound and fluoroscopic guidance in interventional radiology, you can easily code the below sample medical coding report. In this report, a non-vascular ultrasound guidance (76942) is used for Cholecystostomy. But, Cholecystostomy exam includes the ultrasound guidance. Hence, the below sample or example report will have only one major CPT codes which will include the ultrasound guidance code as well. Now, just go ahead and try to solve the below sample medical coding report and check the correct codes later.
US GUIDED CHOLECYSTOSTOMY
ADDENDUM Ultrasound imaging suggests subtle surface nodularity involving the liver. These findings can be seen in the setting of cirrhosis.
PROCEDURE: ULTRASOUND GUIDED CHOLECYSTOSTOMY DRAINAGE. ULTRASOUND- GUIDED DIAGNOSTIC PARACENTESIS.
INDICATIONS: 50-year old female with suspected cholecystitis. Percutaneous drainage has been requested. Ultrasound imaging demonstrates the gallbladder wall thickening and sludge. Clinically, the patient has signs of severe sepsis and hepatic decompensation.
MEDICATIONS: See nursing record. Moderate sedation was monitored by the ICU nurse.
COMPLICATIONS: None Immediate.
PROCEDURE: Written informed consent was obtained in a SPARQ conference with the patient. The patient was prepped and draped in the usual manner. This procedure was performed at the ICU bed side. A small fluid collection in the right upper quadrant was identified compatible with ascites. The skin was anesthetized with 1% lidocaine and the yueh needle catheter was advanced into the peritoneal space. Approximately 6 ml of serous fluid was aspirated. Subsequently, using local anesthetic and US guidance a Yueh needle was advanced into the gallbladder from a anterior subcostal approach. Thick dark bilious fluid was aspirated and sent to the laboratory for further evaluation. Over a guidewire serial dilatation was performed and a 10 French multipurpose drainage catheter was advanced into the collection using CT guidance. The catheter was aspirated and placed to gravity bag drainage. The catheter was sutured in place. A completion ultrasound was obtained.
FINDINGS: Ultrasound imaging of the gallbladder demonstrates wall thickening and sludge. Real time imaging demonstrates realization of a needle catheter within the gallbladder to allow percutaneous access. Completion imaging demonstrates appropriate positioning of a 10-French drainage catheter within the gallbladder. Ultrasound imaging also demonstrates a small amount of fluid within the right upper quadrant. Real time imaging demonstrates appropriate positioning of a Yueh needle catheter with an the fluid collection to allow diagnostic paracentesis.
IMPRESSION: Successful ultrasound-guided percutaneous cholecystostomy tube placement and diagnostic paracentesis.
CPT: 47490, 49083
ICD 10: K82.8, R18.8
ICD : 575.8, 789.59
Medical coding Examples – 3
Below sample medical coding report, is also a good example for diagnostic radiology coders. This coded sample chart below is about PET CT exam. This exam is very commonly coded in radiology. Also the use of PI (Initial staging) and PS(subsequent staging) modifiers along with PET CT scan CPT codes should not be forgot. So, lets just go through the below sample medical coding report for radiology coder and try to solve or code it. If you can code this report, you can easily code the X-ray, CT, MRI etc reports in radiology facility.
PET CT SKULL BASE TO MID THIGH
INDICATION: Malignant neoplasm of thoracic esophagus (HCC)
PET/CT IMAGING, SKULL BASE TO MID THIGH
INDICATION: Malignant neoplasm of thoracic esophagus. Restaging.
COMPARISON:S: PET/CT study dated 26 Feb 2014
PROCEDURE: Prior to administration of F18-fluorodeoxyglucose (FDG), the fasting blood glucose level measured by glucometer was 112 mg/dL. Approximately one hour after the intravenous administration of 15.3 mCi of F18-FDG and oral administration of contrast, emission PET images of the body were obtained from the cranial vertex to the mid-thighs. Noncontrast CT images were obtained for attenuation correction and for fusion with the emission PET images. (The noncontrast CT images are not of diagnostic quality and are not used to diagnose disease independently of the PET images.)
SKELETON: There are no areas of abnormal FDG uptake.
HEAD AND NECK: There are no areas of abnormal FDG uptake in the soft tissues.
CHEST: Left supraclavicular lymph node measures 1.2 x 0.7 cm (was 1.7 x 1.4 cm) and shows increased FDG uptake with max SUV of 4.5 (was max SUV of 5.5). Multifocal areas of ground-glass lung opacities in the right upper lobe show slightly increased FDG uptake with max SUV of 3.1.
ABDOMEN: There are no areas of abnormal FDG uptake in the soft tissues.
PELVIS: There are no areas of abnormal FDG uptake in the soft tissues. Physiologic distribution of FDG is seen in the brain, colon and GU tract.
FINDINGS: There are surgical changes from esophageal resection and cholecystectomy. Nonobstructive stones are seen in bilateral kidneys. The colon contains a large amount of retained fecal material.
IMPRESSION: 1. Persistent FDG uptake in left supraclavicular lymph node, which has become slightly smaller.
- Multifocal areas of ground-glass opacities in the right lung with mild FDG uptake suggestive of an infectious or inflammatory process. In comparison to the prior study, this PET/CT study shows decreased size of metastatic lymph node in the left supraclavicular region but no new metastases.
ICD 10: C15.9, R91.8
ICD: 150.9, 793.19
Hope, these sample medical coding examples charts will help you to learn about coding CPT and ICD codes in detail. Do share your thoughts in comment section.