Comments on what I missed reading this Radiology Report

Discussion in 'Medical Coding & Reimbursement Discussion' started by Sparky, Dec 18, 2012.

  1. Sparky

    Sparky Well-Known Member

    Radiology Report
    EXAMINATION: MRI of brain with contrast
    CLINICAL SYMPTOMS: Slurred speech, right arm weakness
    MAGNETIC RESONANCE EXAMINATION OF THE BRAIN was performed prior to contrast
    utilizing T1-weighted sagittal views as well as spin density and T2-weighted sequences in the axial plane. These were supplemented with axial T1-weighted sequence following intravenous infusion of paramagnetic contrast material. Diffusion sequence was also performed.

    In the spin density and T2-weighted sequences (images 17 and 18 of series 3), there is a small localized area of occipital cortex that shows increased intensity. This is also bright in the diffusion sequence. This area is not hyperintense in the ADC map.
    I do not appreciate significant abnormal increased or decreased intensity within
    brain parenchyma of the remainder of the supratentorial brain. However, there is
    bilateral irregularly shaped increased intensity within the pontine tegmentum. This
    is not hyperintense in the diffusion sequence. Ventricles are of normal size. Normal gray-white matter delineation. No abnormal contrast enhancement of brain parenchyma.

    IMPRESSION: Small hyperintense area of the cortex of the right occipital lobe, as
    described above. This is also hyperintense in the diffusion sequence but not in the
    ADC map. This would indicate that this represents limited subacute infarction. I do
    not appreciate other areas of subacute infarction. Remainder of supratentorial portion
    of the brain is unremarkable. Hazy increased intensity within the pontine tegmentum. This is not unusual in the older age group (8th and 9th decades) and is sometimes thought to represent evidence of microvascular ischemic change. However, it is rarely indeterminate. In this
    case, I do not appreciate evidence of enlargement of the brainstem, nor is there
    abnormal enhancement to suggest neoplasm. I cannot elucidate further.

    Answer: CPT Code: 70552 (Comments: Incorrect code)
     
  2. Laureen

    Laureen Queen Instructor Staff Member Administrator Moderator MTA Student Replay Cluber PPM Student (CPPM®) PBC Student (CPC®) Blitzer CCO Support Staff FBC Student (CPC-H®) ICD-10-CM Student

    For this one you started off right going to 70552

    [​IMG]

    but if you look closer the report you'll see "MAGNETIC RESONANCE EXAMINATION OF THE BRAIN was performed prior to contrast" so they actually did a WITHOUT contrast followed by a WITH contrast which would be 70553.


    The old fashioned way to describe this studies is DRY for without, WET for with contrast, and WETDRY for both. This is how they are presented in their respective bubbles. The top code is the DRY code, the second code is the WET code and the third code is the WETDRY code.

    Use procedure titles to get you started then confirm details with body of report.
     
  3. Sparky

    Sparky Well-Known Member

    Laureen, Thank you so much for the prompt response and the breakdown. I have to try harder to read the studies better and not skip any words within. I was just reviewing a small clip of your webinar and I do like how you say to highlight the codes and breakdown the correct sequence, that they usually are in three. I signed up for your webinar tonight, I have to keep practicing and work harder to understand the language in the scenarios. I truly do appreciate the support and knowing I have a place to ask questions. I wish I knew about your program before starting with Penn Foster. I am hoping to learn more from you and everyone that is a part of this forum. Thank you.
     
  4. Michele

    Michele CPC PBC Student (CPC®) Blitzer

    Laureen thank you for going over this in the webinar tonight. You made it much clearer, I understand it better now.
     

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