Medical Coding Examples Part 1

Medical Coding Example 1

EXAM: NM GASTRIC EMPTYING STUDY

REASON FOR STUDY: Nausea and vomiting

CLINICAL HISTORY: Nausea and vomiting

TECHNIQUE:
A standard meal consisting of Eggbeater 4 oz, toast, jam and water was labeled  with the radiopharmaceutical and administered orally to the patient.  Subsequent static images were obtained at approximately 60 minutes, 120 minutes, 180 and 240 minutes. The images were subsequently used to compute the gastric half emptying time.
Allergies: The patient has no known medication allergies. Radiopharmaceutical: Tc-99m sulphur colloid 760 mCi PO.

FINDINGS:
There is prompt radiopharmaceutical accumulation within the stomach. There is subsequent movement of the radiotracer into the proximal gastrointestinal tract. The emptying fraction (at interpolated times) are as tabulated:

Time (minutes) % remaining normal range remaining
60 74% (37-90 %)
120 60% (30-60 %)
240 1 (0-10 %)

IMPRESSION:
1. Normal gastric emptying scan

Medical Coding Examples Part 1

Read also: When to use Carotid ultrasound CPT code 93880 & 93882

CPT code : 78264

Gastric emptying imaging study;

HCPCS A9541 Technetium Tc-99m sulfur colloid, diagnostic, per study dose, up to 20 millicuries

ICD 10: R11.2  Nausea with vomiting, unspecified

Rationale: The above report is a Nuclear medicine exam for gastric emptying scan. In this procedure, a radiopharmaceutical agent is administered orally and hence HCPCS code A9541 is reported as additional code.

 

Medical coding Example 2

EXAM: NM THREE PHASE BONE SCAN

REASON FOR STUDY:  Pain in right knee, :

CLINICAL HISTORY:
Right knee pain. History of arthroplasty.

COMPARISON: None

TECHNIQUE:
3 phase bone scan was performed of the bilateral knees. 20 mCi of Tc-MDP was injected intravenously. Medication reconciliation form reviewed and any changes related to this procedure resolved.

FINDINGS:
There are postsurgical changes of bilateral knee arthroplasty. There is no increased radiotracer uptake in the bilateral periarticular regions on the flow and blood pool phases. There is symmetric focal periarticular increased uptake bilaterally on the delayed phase, particularly along the tibial component.

IMPRESSION:
1. Expected postsurgical changes of bilateral knee arthroplasty. No scintigraphic evidence to suggest prosthetic complication.

CPT code: 78315

Bone and/or joint imaging; 3 phase study

A9503 – Technetium tc-99m medronate, diagnostic, per study dose, up to 30 millicuries

ICD 10: M25.561 Pain in right knee

Rationale: This procedure is also a Nuclear medicine bone scan, CPT code 78315. In this exam, also a radiopharmaceutical agent Medronate (MDP) is injected, hence a HCPCS code A9503 is assigned. 

Read also: Best coding guide for imaging Guidance CPT codes

               

Medical Coding Example 3

EXAM: SAT SONO ABDOMEN

REASON FOR STUDY: 63634009: Glioblastoma, :

CLINICAL HISTORY: History of glioblastoma

COMPARISON: February 21, 2018 CT

TECHNIQUE:
The study was performed in an ACR accredited facility. Multiple transverse and longitudinal views of the abdomen were obtained.

FINDINGS:
Liver: Multiple round to lobular shaped anechoic parenchymal foci compatible with cysts the largest measuring 3.9 cm within the left hepatic lobe. The next largest hepatic cyst is noted within segment 4 of the liver measuring 1.6
cm. Background liver parenchyma is normal in echogenicity. Liver contour is within normal limits.
Spleen: Unremarkable.
Gallbladder: Echo-free without evidence of gallstones or sludge.
Biliary ducts: No evidence of biliary dilatation. The common bile duct
measures 4 mm.
Kidneys: No masses or hydronephrosis.
Pancreas: Unremarkable.
Free fluid: None.
Aorta: Unremarkable.
Inferior vena cava: Unremarkable.

IMPRESSION:
1. Hepatic simple cysts measuring up to 3.9 cm in size. Otherwise unremarkable abdominal sonogram.

CPT code: 76700

Ultrasound, abdominal, real time with image documentation; complete

ICD 10: C719 Malignant neoplasm of brain, unspecified

Rationale: The above report is an ultrasound exam of abdomen, complete. In this exam, the present of eight organs(liver, spleen, gallbladder, biliary or CBD, aorta, kidneys, inferior vena cava, pancrease) must be documented for complete ultrasound of abdomen, CPT code 76700. If any organ is missing, then we should checkout with the payer, to code it as limited ultrasound of abdomen 76705.

Read also: Best coding tips for ABI index CPT code 93922 & 93923

Medical coding Example 4

EXAM: SAT SONO KIDNEY

REASON FOR STUDY:  Hydronephrosis, :

CLINICAL HISTORY: Hydronephrosis

TECHNIQUE:
The study was performed in an ACR accredited facility. Multiple transverse and longitudinal sonographic images of the kidneys and urinary bladder were performed.

FINDINGS:
The right kidney measures 12.6 cm and the left kidney measures 12.7 cm. The kidneys are increased in echogenicity. There is a 4.7 cm exophytic simple cyst in the upper pole the left kidney. There is moderate to severe right hydronephrosis, not significantly changed. No left hydronephrosis.

The urinary bladder is unremarkable with presence of bilateral ureteral jets. No postvoid residual.

IMPRESSION:
1. Moderate to severe right hydronephrosis, unchanged. Medical renal disease.

CPT code : 76770

Ultrasound, retroperitoneal, real time with image documentation; complete

ICD 10: N13.30 Unspecified hydronephrosis

N281 Cyst of kidney, acquired

Rationale: The above exam is a completed ultrasound of kidney, CPT code 76770. The complete exam for renal ultrasound should have documentation of two kidneys, urinary bladder and the renal diagnosis (hydronephrosis, in this report). 

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