CPC Chapter 17- Radiology Practical Flashcards
CASE 1
Location: Imaging center, radiologist employed.(Radiologist is employed by the imaging center: the imaging center should report the global component.)
STUDY: FEMUR AP AND LATERAL(2 views taken.)
REASON: LEFT LEG PAIN
LEFT FEMUR:
COMPARISON: There are no prior studies for comparison.
FINDINGS: There is no fracture or dislocation of the left femur. The femoral head is concentrically seated within the acetabulum without deformity of the femoral head.
IMPRESSION: Normal (Findings are normal, the reason for the study is used for the diagnosis.) views of the left femur.
What are the CPT® and ICD-10-CM codes reported for this service?
73552-LT
M79.605
CASE 2
Location: Regional Hospital(The hospital will report the technical component. Only the professional component should be reported.)
MRI OF THE LUMBAR SPINE
History: Low back pain.(Reason for the MRI, also known as Lumbago.)
Technique: On a 1.5 Tesla magnet multiple sagittal and axial(Sagittal and axial images were taken.) images were performed through the lumbar spine(Location—lumbar spine.) using variable pulse sequences.
Findings: There is normal lumbar alignment. The conus is in normal position at the thoracolumbar junction. No suspect bone marrow lesions are present. There is mild anterior wedging of the L3 vertebral body. I am uncertain whether this is an acute or chronic finding.
At the T12-L1 level, there is a small posterior disc bulge. There is no central canal stenosis. There is no neural foraminal stenosis.
At the L1-2 level, there is no disc bulge or protrusion. There is no central canal or neural foraminal stenosis.
At the L2-3 level, there is moderate loss of disc height. There is 106s of T2 signal. There is a focal area of increased T1 signal involving the L2-3 disc. This could be related to disc calcification or possibly blood product. There is a small posterior disc bulge. There is no central canal stenosis. There is no neural foraminal stenosis.
At the L3-4 level, there is a minimal posterior disc bulge. There is no central canal stenosis. There is no neural foraminal stenosis.
At the L4-S level, there is mild loss of disc height and loss of T2 disc signal. There is a moderate size right paracentral disc protrusion impinging the anterior aspect of the thecal sac. There is no central canal stenosis. There is no neural foraminal stenosis.
At the L5-S1 level, there is no disc bulge or disc protrusion. There is no central or neural foraminal stenosis.
IMPRESSION: Mild anterior wedging of the L3 vertebral body.(Wedging of vertebrae is considered Osteoporosis.) It is uncertain whether this is acute or chronic finding. There is increased T1 signal involving the L2-3 disc which could be related to calcification or possible hemorrhage although this is felt to be less likely.
Moderate size right paracentral disc protrusion at L4-5.(Disc protrusion is coded as intervertebral disc displacement and is in the lumbar region.) Multilevel degenerative disc disease.(Degenerative Disc Disease covers more than one level in the lumbar spine.)
What are the CPT® and ICD-10-CM codes reported for this service?
72148-26
M48.56XA, M51.26, M51.36
CASE 3
Location: Imaging center; radiologist employed.(Radiologist is employed by the imaging center: the imaging center should report the global component.)
STUDY: MAMMOGRAM BILATERAL SCREENING,(Screening bilateral mammogram.) all VIEWS, PRODUCING DIRECT DIGITAL IMAGE
REASON: SCREEN
BILATERAL DIGITAL MAMMOGRAPHY WITH COMPUTER-AIDED DETECTION (CAD) (Use of CAD.)
No previous mammograms are available for comparison.
CLINICAL HISTORY: The patient has a positive family history of breast cancer.(Family history of breast CA.)
Mammogram was read with the assistance of GE iCAD (computerized diagnostic) system.
FINDINGS: Residual fibroglandular breast parenchymal tissue is identified bilaterally. No dominant spiculated mass or suspicious area of clustered pleomorphic microcalcifications are apparent. Skin and nipples are seen to be normal. The axilla is unremarkable.
IMPRESSION: BI-RADS 1—Negative (Negative screening.)
What are the CPT® and ICD-10-CM codes reported for this service?
77067
Z12.31, Z80.3, R92.313
CASE 4
Location: Independent Diagnostic Testing Facility, radiologist employed by the facility. (Radiologist is employed by the facility, the IDTF will bill for global component.)
CT BRAIN/HEAD W/WO CONTRAST EXAM: CT Head, without and with Contrast August 5, 20XX.
COMPARISON: None available.
HISTORY: Non-small-cell lung cancer. (Patient has non-small cell lung cancer, not specified to location in lung.)
TECHNIQUE: Axial images of the calvarium without and with (CT performed without and with contrast.) 125 cc Omnipaque-300 intravenous contrast. (Contrast was intravenous.)
FINDINGS: The calvarium is intact. Imaged upper portions of the maxillary antra show minimal mucosal thickening. The sphenoid ethmoid and frontal sinuses are clear bilaterally. No hydrocephalus, mass effect, brain shift, abnormal extra-axial fluid collection or mass. Calcification left basal ganglia without mass effect, nonspecific, likely benign. Abnormal but nonspecific decreased density in the periventricular and subcortical white matter of the cerebral hemispheres bilaterally without mass effect or enhancement, most consistent with remote microvascular ischemic change present to mild degree. Bilateral intracavernous carotid and vertebral arteriosclerotic calcification. Probable anterior communicating artery aneurysm 6 x 5 mm. Recommend intracranial CT angiography to further characterize.
CONCLUSION: 1. No finding suggestive of metastatic disease. 2. Probable (Aneurysm is probable and would not be coded.) 6 x 5 mm anterior communicating artery aneurysm. Recommend intracranial CT angiography to further characterize. 3. Cerebrovascular arteriosclerosis. (Additional diagnosis of cerebrovascular arteriosclerosis.) 4. Nonspecific cerebral white matter lesions (Additional diagnosis of cerebral lesions.) most consistent with remote microvascular ischemic change. 5. Calcification left basal ganglia,(Additional diagnosis of calcification left basal ganglia.) likely benign; however, recommend continued imaging follow-up.
What are the CPT® and ICD-10-CM codes reported for this service?
70470
C34.90, I67.2, G93.9, G23.8
CASE 5
Location: Regional hospital. (Provided at the hospital, the radiologist will report the professional component.)
Study: Ultrasound Urinary Tract
Indications: Status ureteral reimplantation (The surgical procedure has been performed. The ultrasound is being performed after a surgical procedure for evaluation of continued reflux.) to evaluate for continued vesicoureteral reflux.
Left Kidney:(Kidney evaluated.)
Length: 7.0 cm
Prior length: 7.4 cm
Parenchyma: Cortical scarring.
Pelvic dilatation: Normal
Calyceal dilatation: Normal
Hydronephrosis grade: Normal
Interval hydronephrosis change: None
Right Kidney:
Length: 6.6 cm
Prior length: 6.4 cm
Parenchyma: Cortical scarring.
Pelvic dilatation: Normal
Calyceal dilatation: Normal
Hydronephrosis grade: Normal
Interval hydronephrosis change: None
Ureters: (Ureters evaluated.) Normal
Bladder: (Bladder evaluated.) Almost empty and difficult to evaluate.
Impression:
1, Interval right renal enlargement without hydronephrosis. (Diagnosis—right renal growth.)
- Stable asymmetric small left renal size (Additional diagnosis—small left renal size.) likely to represent diffuse cortical scarring.
What are the CPT® and ICD-10-CM codes reported for this service?
76770-26
Z48.816, N13.70, N28.81, N27.0
CASE 6
Location: Regional Hospital
Fluoro Hysterosalpingogram
EXAMINATION:
HYSTEROSALPINGOGRAM (PROCEDURE PERFORMED 8Y RADIOLOGIST)
INDICATION:
Infertility for 15 years. Patient had one child 15 years ago. Last menstrual period was 1/13/20XX.
No history of pelvic infection or surgery
COMPARISON: None
PROCEDURE:
The examination and anticipated discomfort was discussed with the patient. A plastic vaginal speculum was introduced with the patient’s legs in the stirrups following preliminary vaginal examination and lubrication. The posterior vaginal fornix and outer cervical os were prepped with a cleansing solution. A 5F hysterosalpingogram catheter was used. The catheter balloon was inflated in the lower uterine segment. Fluoroscopic and radiographic assessments were done.
The patient tolerated the procedure well.
FINDINGS:
Contrast was administered through the catheter and multiple images were taken. There is a possible abnormal contour to the right cornua with patchy contrast opacification which may represent intramural contrast with intravasation.
No definite spillage of contrast from either fallopian tube was identified
IMPRESSION:
- Possible right cornual contour abnormality manifested by focal extravasation and minimal intravasation of undetermined etiology. Recommend endovaginal ultrasound for further evaluation.
- No contrast filling of either tubes and no spill into pelvic peritoneal space.
What are the CPT® and ICD-10-CM codes reported for this service?
58340, 74740-26
N97.9
CASE 7
Location: Regional Hospital
CT THORAX W/CONTRAST,CT ABDOMEN W/CONTRAST,CT PELVIS W/CONTRAST,Low Osmolar Contrast
EXAM: CT Chest with Contrast; CT Abdomen with Contrast; CT Pelvis with Contrast August 5, 20XX.
COMPARISON: CT chest Regional Hospital 7/8/20XX.
HISTORY: Non-small-cell lung cancer.
TECHNIQUE: Axial images of the chest, abdomen pelvis with oral and 125 cc Omnipaque-300 intravenous contrast.
FINDINGS: Chest CT shows left upper lobe and pulmonary mass which appear centrally necrotic abutting the posterior pleural surface and mediastinum without definitive invasion, 83 x 64 mm, prior 76 x 56 mm, image 15. Stable lingular and left basilar, right middle lobe and right lower lobe superior segment pleural-parenchymal opacity suggesting scarring. New mild subsegmental infiltrate left upper lobe. No pneumothorax or pleural fluid. No thoracic adenopathy. Heart size normal, no pericardial effusion. Left coronary arteriosclerotic calcification present. No osseous neoplasm. Abdomen CT shows normal liver, gallbladder, biliary ducts, pancreas, spleen, adrenal glands and kidneys. Stomach and duodenum within normal limits. Aortoiliac arterial sclerosis without aneurysm. No retroperitoneal adenopathy. Pelvis CT shows no mass, adenopathy or ascites. No bowel obstruction. No hernia. No osseous neoplasm. Lumbar spine degenerative change present. Left-sided muscle atrophy and brace noted.
Conclusion: 1. Increasing size left upper lobe pulmonary mass with central cavitation suggested. 2. No thoracic adenopathy or distant metastatic disease demonstrated. 3. Coronary arteriosclerosis.
What are the CPT® and ICD-10-CM codes reported for this service?
74177-26, 71260-26
C34.12, I25.10
CASE 8
Location: Regional Hospital
EXAM:
Renal and bladder ultrasound dated 10/01/20XX
Renal artery Doppler evaluation dated 10/01/20XX
COMPARISON:
Renal MRA dated 04/01/20XX
HISTORY:
80-year-old with renal artery stenosis. Diagnostic ultrasound of the kidneys was ordered to see if there was kidney damage due to the renal stenosis or other kidney issues. This was followed after review with a renal Doppler study.
FINDINGS:
Multiple grayscale sonographic and color Doppler images of the kidneys and renal vasculature were submitted for interpretation.
The right kidney measures 10.1 cm without evidence of pelvic caliectasis.
There is a small 8mm cyst noted within the lower pole of the right kidney. There is relatively normal internal architecture and echogenicity. The left kidney measures 10.4 cm with no evidence of pelvicaliectasis. There are at least 3 renal cysts identified, the largest measuring 2 cm in diameter. There is normal internal architecture and echogenicity. The bladder is distended with urine and appears within normal limits.
The aorta demonstrates peak systolic velocity of 1.07 m/sec.
The right renal artery origin demonstrates peak systolic velocity of 3.0 m/sec with a resistive index of 0.92. The midportion of the right renal artery demonstrates a peak systolic velocity of 1.1 m/sec with resistive index of 0.8. The right renal hilum has a peak systolic velocity of 0.64 m/sec with resistive index of 0.85. The inferior pole has a systolic velocity of 0.16 m/sec with resistive index of 0.54. The midpole has a systolic velocity of 0.18 m/sec and resistive index of 0.70.
The superior pole has a velocity peak of 0.22 m/sec with a resistive index of 0.77.
The left renal artery origin demonstrates a peak systolic velocity of 2.0 m/sec with a resistive index of 0.87. The mid portion of the left renal artery demonstrates a peak velocity at 0.42 m/sec and a resistive index of 0.80. The left renal hilum has a peak systolic velocity of 0.47 m/sec and a resistive index of 0.82. The inferior pole has a systolic velocity of 0 16 m/sec and a resistive index of 0.67. The midpole has a systolic velocity of 0.17 m/sec and a resistive index of 0.63.
The superior pole has a velocity peak of 0.13 m/sec with a resistive index of 0.69.
IMPRESSION:
RENAL ARTERY DOPPLER STUDY:
- Moderate stenosis of the right renal artery origin.
- Mild to moderate left renal artery origin stenosis.
RENAL AND BLADDER ULTRASOUND:
- Bilateral probable renal cysts.
- Normal appearing bladder
What are the CPT® and ICD-10-CM codes reported for this service?
93976-26, 76770-26-59
I70.1
CASE 9
Location: Regional Hospital
EXAMINATION:
- CT ENTEROCLYSIS (FLUORO ENTEROCLYSIS WITH CT ABDOMEN - NEUTRAL ENTERAL WITH IV CONTRAST- 2D REFORMATS)
- CT ENTEROCLYSIS (FLUORO ENTEROCLYSIS WITH CT PELVIS - NEUTRAL ENTERAL WITH IV CONTRAST - 20 REFORMATS)
Clinical Indication:
Unexplained abdominal pain and diarrhea, as well as weight loss.
Normal colonoscopy.
Comparison: None.
PROCEDURE:
In accordance with policy and procedure standard medication reconciliation was performed by the radiologic technologist prior to IV contrast administration. No contraindication was identified.
The examination was performed in accordance with the standard protocol on a 43-year-old male.
Following preprocedure assessment, informed consent was obtained. Conscious sedation Independent observation performed by Amy Smith, RN. Total Time of Sedation: 60 minutes. Vital signs, pre-procedure and post-procedure monitoring were done by nurse in attendance with me performing the conscious sedation. A transnasal intubation was done following a nasal drop of a local anesthetic.
Under fluoroscopic guidance, using guidewire and positional maneuvers, the enteroclysis catheter was advanced and the tip anchored at the distal horizontal duodenum.
Neutral enteral contrast was infused and monitored to a total of approximately 3.5 L. 0.6 mg Glucagon was administered IV prior to IV contrast administration. CT acquisition was done during continued infusion of enteral contrast following a 45 to 50 seconds delay. Intravenous administration of 100 ml lsovue 370 at 4 ml/second infusion rate. CT parameters used were 40 x 0.625 mm collimation reconstructed at 2 mm section thickness reconstructed at 1 mm intervals. The source images were transferred to an independent workstation (EBW) and cross referenced multiplanar interactive 2D interpretation was done by the radiologist. Images were reviewed using soft tissue window settings.
Following completion of the infusion, the catheter was withdrawn into the stomach and refluxed contrast removed prior to catheter removal.
No acute adverse events occurred.
FINDINGS:
There is no evidence of transmural inflammatory disease changes involving the small bowel or the colorectum. There is, however, mild prominence of the vasa recta in the right lower abdomen, mild increased attenuation of the cecum and ascending colon and adjacent distal small bowel. Suggest biopsy at the ascending colon to exclude microscopic colitis. If the patient has a history of blood in the stools, air double-contrast enteroclysis would be of value to exclude aphthous ileitis. CT enteroclysis may not be able to assess for early Crohn’s until transmural involvement is seen. The rest of the colon also appears normal.
There are no fold changes to suggest adult celiac disease.
There is no evidence of a small bowel mass. The mesentery appears normal.
Solid abdominal organs are grossly unremarkable.
IMPRESSION:
- No evidence of transmural inflammatory disease changes involving the small bowel or colorectum. No fold abnormalities to suggest sprue.
- Prominence of vasa recta of cecum and ascending colon and distal ileum with question of mild increased attenuation. Consider microscopic colitis. See discussion and recommendation above.
If there is strong clinical suspicion of Crohn’s disease, consider air DC barium enteroclysis to exclude or confirm early aphthoid changes.
- Reproduction of abdominal pain during contrast infusion, thus, correlated for visceral hypersensitivity.
- Solid abdominal organs grossly unremarkable.
What are the CPT® and ICD-10-CM codes reported for this service?
74177-26, 74340-26, 44500, 99152, 99153 X3
R10.9, R19.7, R63.4
CASE 10
Location: Regional Hospital
TYPE OF PROCEDURE:
- Abdominal aortic angiogram
- Mesenteric artery angiogram
HISTORY: Mesenteric ischemia.
INFORMED CONSENT: The procedure was discussed with the patient and his wife. The risks, including bleeding, infection and vascular injuries such as dissection, perforation, thrombus, and embolus were outlined. Informed consent was obtained.
CONTRAST: 123 ml Ultravist 370.
DESCRIPTION OF PROCEDURE: The patient’s right groin was sterilely prepped and draped. The skin and subcutaneous tissues were anesthetized with 2% lidocaine. The right common femoral artery was then percutaneously accessed and a wire advanced into the abdominal aorta under fluoroscopic visualization. A 5-French vascular sheath was placed into the right groin. An Omni Flush catheter was advanced to the upper abdominal aorta. Digital subtraction angiography of the abdominal aorta was performed. It demonstrates mild tortuosity of the aorta. The caliber is normal. A single renal artery is seen bilaterally without stenosis. The common iliac vessels are patent.
The Omni Flush catheter was then exchanged for a Cobra 2 catheter. The superior mesenteric artery was then selectively catheterized. Digital subtraction angiography was performed in multiple obliquities. The origin is patent. No focal stenosis or branch occlusions are identified. Next, the celiac artery was selectively catheterized. Digital subtraction angiography was performed in 2 obliquities. The origin is normal. No focal stenosis or branch occlusions are present.
Next, attempts were made to catheter the inferior mesenteric artery with the Cobra 2 catheter. This was unsuccessful. Selective catheterization of the inferior mesenteric artery was achieved with a Simmons 2 catheter. Digital subtraction angiography was then performed in 2 obliquities. The origin is patent. No stenosis or branch occlusions are present. The Simmons 2 catheter was removed as was the right groin sheath over a wire. Hemostasis in the right groin was then achieved using an Angio-Seal closure device.
IMPRESSION: Normal abdominal aortic angiogram and mesenteric angiogram of selective catheterization of the celiac, superior mesenteric and inferior mesenteric arteries.
What are the CPT® and ICD-10-CM codes reported for this service?
36245, 36245-59, 36245-59, 75726-26, 75726-26-59
75726-26-59, K55.9
