Sample IVR or Interventional radiology coding charts

Medical coding Sample coded Report – 1

US BREAST BIOPSY RIGHT 

HISTORY: Suspicious 11 mm solid palpable lesion 5:00 6 cm from the nipple. 

PROCEDURE: Risks and procedure were discussed with the patient in Spanish and written informed consent was obtained.

The right breast was prepped and draped in the usual manner.  Buffered 1% lidocaine was used for skin anesthesia followed by buffered 1% lidocaine mixed with epinephrine for deeper anesthesia.  Small skin incision made.  Under sonographic guidance, a Suros 12-guage vacuum assisted core biopsy needle device was then used to obtain six core samples of the solid mass at 5:00 6 cm from the nipple.  A clip was placed at the site of biopsy via the Suros device. The needle was withdrawn and pressure applied to ensure adequate hemostasis. Minimal blood loss noted, no complication, and the patient was without complaint.  Patient was provided postprocedural precautions verbally and in writing and will be notified via telephone once pathology results are made available.  

SUMMARY: Ultrasound-guided vacuum assisted core biopsy of the right breast.

CPT – 19083-RT

ICD 10 – N63.10

 

Sample IVR or Interventional radiology coding charts

Medical coding Sample coded Report – 2

NEEDLE WIRE LOCALIZATION, RIGHT BREAST
INDICATION: Carcinoma in situ of breast, right

HISTORY: Malignancy in the inferior medial right breast. The target is a metallic clip and some residual calcifications.

TECHNIQUE: Using digital technique, the lesion in question was imaged. Using a medial approach, a 21 gauge needle was placed adjacent to the lesion. 0.3 ml of methylene blue were injected at the needle tip. The needle was replaced with the hook wire. The patient tolerated the procedure well. Subsequent mammography reveals that the wire is adjacent to the area in question.

               

IMPRESSION: Successful needle wire localization of the right breast lesion.

CPT – 19281-RT

ICD 10 – D05.91

 

Medical coding Sample coded Report – 3

PROCEDURE: CT GUIDED RIGHT UPPER LOBE LUNG BIOPSY

HISTORY:  Enlarging Right Upper Lobe Lung mass, Clinical conern for Malignancy

COMPLICATIONS: None.


PROCEDURE DESCRIPTION
: After obtaining informed consent in a SPARQ conference, the patient was prepped and draped in the usual sterile fashion. The right upper lobe mass was localized under CT guidance and the skin was anesthetized with 1% lidocaine. Subsequently, a 18 gauge introducer needle was advanced into the mass under CT guidance. Three 20 gauge core biopsies were performed. Samples were placed in both sterile saline and formalin and sent to pathology for further evaluation.

Post biopsy completion imaging was performed. The patient tolerated the procedure well and without complication.

FINDINGS: CT imaging again demonstrates a mass within the lateral aspect of the right upper lobe.  Imaging demonstrates appropriate positioning of the biopsy needle within this lesion to allow tissue sampling. Completion imaging demonstrates ground-glass opacities surrounding the biopsy site compatible with hemorrhage. There is no pneumothorax.

IMPRESSION: Technically successful CT guided right upper lobe lung biopsy.

CPT – 32408

ICD 10 – J98.4

Medical coding Sample coded Report – 4

INDICATION: Malignant neoplasm of breast (female), unspecified site (HCC)

SENTINEL NODE INJECTION, right breast The procedure was performed by Dr. Richard. Following sterile preparation of the skin, a total of 0.55 mCi of Technetium sulfur colloid was injected into the right periareolarbreast in four separate aliquots. She tolerated this well.

CPT – 38792

ICD 10 – C50.911

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19 Thoughts to “Sample IVR or Interventional radiology coding charts”

  1. […] of catheter, you can understand what is Selective and Non Selective Catheter Placement? Also in interventional radiology coding, we sometimes use ipsilateral(antegrade) or contralateral(retrograde) direction to document the […]

  2. […] have separate CPT code for lumbar and cervical myelogram. Similarly, we have separate radiology myelography CPT Codes for both. We should never forget to code Supervision and interpretation CPT […]

  3. […] of guidance is very common for performing any radiology diagnostic exam. Interventional radiology CPT codes are mostly accompanied by guidance CPT codes. Fluoroscopy, Ultrasound, Computed tomography, MRI […]

  4. […] interventional radiology, we have many CPT codes for Biopsy procedures. Breast biopsy has the most number of CPT codes to […]

  5. […] taking images. You can also read my article of abdominal aortogram with runoff CPT codes used for interventional radiology procedures. Now, here the report will mention findings from aorta, abdomen, pelvis and both the lower […]

  6. […] 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 […]

  7. […] are the most common site to study during Interventional radiology coding. Mostly lower extremities are studying while performing aortogram without runoff. The catheter is […]

  8. […] surgery, it is very important to code the angiography codes for studying the arteries or veins. In interventional radiology, we have many CPT codes for angiograms that are specific are each artery or vein. These Angiogram […]

  9. […] codes are important in Interventional radiology coding. Percutaneous surgery procedure is mostly depending upon guidance like ultrasound or fluoroscopic […]

  10. […] role in human body. The biopsy of thyroid gland helps in finding the diagnosis in thyroid gland. In Interventional radiology medical coding, CPT code for ultrasound guided biopsy of thyroid is frequently used. For diagnostic radiology, CPT […]

  11. […] are diagnostic procedures to obtain a tissue sample from the body in order to examine it. In interventional radiology, we have separate CPT codes for biopsy of different parts of the body. The most common and diverse […]

  12. […] surgeries. With moderate conscious sedation the patient responds purposefully to verbal commands. Interventional radiology and open surgery procedures requires moderate conscious sedation. But, from 2017 new cpt codes have […]

  13. […] biopsies are very common procedure in interventional radiology coding. When I started coding breast biopsy, I used to code the biopsy and imaging guidance separately. […]

  14. […] procedures, which have different encounter on same day with same physician. Here, we will take an example from radiology charts. Let us say the patient has come with an ankle fracture in the morning to the physician. The […]

  15. […] Radiology procedures are very useful for studying any structure of the body. Brain, which is a very vital part of human body, is also studied very carefully using radiology techniques. Having knowledge about anatomy and physiology helps in coding ICD 10 and CPT codes. If you are perfect in coding medical report, it will helps in preparing for certification exam like CPC without taking any training.  MRI, a three-dimensional scan to study any structure of body, is also used for studying head or brain. In MRI, a dye or a contrast can also be introduced to study the particular area of the body. We have separate CPT code for MRI brain or head with or without using of contrast. We will just learn how to use these CPT codes for coding Radiology medical charts. […]

  16. […] facility, I was given a training for 1 month. Now, this training really helped in coding the complex sample interventional radiology charts. This facility was really interesting because of the way codes used for coding. Even after going […]

  17. […] after Arthrogram or Myelogram will always be considered as with contrast. If you know about Interventional radiology procedures, you will know that MRI spine exam is performed after diagnostic arthrogram or myelogram. In this […]

  18. […] website has everything which a coder need. It has articles from all the facility like ED, radiology, surgery, outpatient, inpatient etc. which increases your knowledge. The best part of this website […]

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