Secrets tips for Radiology coding with sample charts

We know coding is not only about finding a ICD 9 or ICD 10 code in books. Medical coding is about how to use those ICD codes for coding a medical chart using coding guidelines. I have shared few tips  of coding 70000 series but one should also know about how the documentation is given in Medical charts. Radiology coding is all about coding X-rays, MRI, CT scan etc. but one should also know that we should have a supported ICD code with these CPT codes. ICD codes should fullfill the medical necessity required to perform that procedure. I have shared already few topics below which will really help you in coding radiology reports.


When to use Renal Scan with Lasix CPT code
Coding tips for coding 73221 CPT code
When to use CPT code 73721
Coding tips for CT scan CPT Code 74177
Main difference between New Breast Ultrasound CPT codes
Coding tips for Thyroid Ultrasound CPT code
 Superb tips for HIDA Scan Coding
 When to use New Modifier XE
Amazing tips for Coding ERCP CPT code
Coding tips for MRCP procedure Code
Basics about Coding Chest X-ray CPT code
Coding guide for bone DEXA scan CPT code
Ultrasound coding tips for Renal exam

After going through these blog post, I hope you will be able to code the below Sample charts from radiology facility. If you are able to get the correct code the you are eligible enough to appear and clear for coding certification exam like CPC.

CPC Practice Exam - Medical Coding Study Guide Please Click Here!

Learn Radiology coding with sample charts


ABDOMEN THREE VIEW SERIES RADIOGRAPHS

INDICATION: abdominal pain.
FINDINGS:
Chest:
There is no acute infiltrate or effusion. Mediastinum is intact.
Abdomen:
A normal, nonobstructed bowel gas pattern is seen.
No free air is seen.
No organomegaly is present.

No abnormal calcifications are demonstrated.

IMPRESSION:
1. No acute findings.

CPT- 74022
ICD10- R10.9
ICD9- 789.00


CHEST SINGLE VIEW RADIOGRAPH:

VIEWS: One views
EXAM DATE AND TIME: 4/24/2014 5:51 PM
INDICATION: chest pain.
FINDINGS:
Lungs: Calcified granuloma left midlung. Right basilar density is
unchanged.
Heart: The cardiac silhouette is normal in size. The thoracic aorta
is normal in caliber.
Osseous Structures: The osseous structures are unremarkable.
Support Catheters: Right internal jugular venous catheter tip near
the cavoatrial junction.
There is no pneumothorax.

IMPRESSION:
1. No change in right basilar findings.

CPT- 71010
ICD10-R07.9
ICD- 786.50


LEFT LOWER LEG TIBIA AND FIBULA RADIOGRAPHS:

VIEWS: Two views
EXAM DATE AND TIME: 4/26/2014 11:54 PM
INDICATION: Leg pain.
FINDINGS:
There is no fracture, proximal or distal dislocation, or other osseous
or soft tissue abnormality. No periosteal elevation or sign of lytic
or blastic changes are present. Visible joints are intact.

IMPRESSION:
1. Negative for acute bony abnormality.

CPT: 73590
ICD10-M79.605
ICD: 729.5


Right elbow Radiograph.
VIEWS: Two views
EXAM DATE AND TIME: 4/26/2014 6:42 PM
INDICATION: Pain
FINDINGS:
No fracture, dislocation or osseous or soft tissue abnormality is
identified in the elbow. The radial head and capitellum appear normal
and there is no displacement of fat pads or effusion.

IMPRESSION:
1. Negative for acute bony abnormality.

CPT: 73070
ICD 10- M25.521
ICD9: 719.42


THYROID CARCINOMA IMAGING, WHOLE BODY:
INDICATION: Thyroid cancer
TECHNIQUE: This was a Thyrogen stimulated exam. 2 mCi of iodine-123
sodium iodide was given orally. Delayed whole body images and spot
images of the neck were obtained at 24 hours
FINDINGS:
There is a normal physiologic distribution of activity in the body.
No foci of uptake are seen to suggest residual functioning thyroid
tissue.
IMPRESSION:
1. No scintigraphic evidence for residual functioning thyroid tissue.
CPT: 78018-26
ICD 10- C73
ICD9:  193

CERVICAL MYELOGRAM:

INDICATION: Previous history of spinal cord injury and cervical spine
fusion. Neck pain. Arm weakness and spasms.

TECHNIQUE: The risks and benefits of the procedure were discussed
with the patient who verbalized understanding. Risks included but
were not limited to bleeding, infection, spinal headache, and allergic
reaction. The patient gave both written and oral informed consent to
proceed. The patient was placed in the prone position on the
examination table and an appropriate window for myelogram injection
identified at the L4-5 level with fluoroscopy. The overlying skin was
prepped and draped in a sterile fashion. Buffered 1% lidocaine used
for local anesthesia. A 5 inch 22-gauge needle was advanced into the
thecal sac at the L4-5 level from a midline approach under
fluoroscopic guidance. Clear and colorless cerebral spinal fluid was
returned. Next, 10 mL of Isovue M 300 contrast material was injected
without difficulty. Following injection, the needle was removed, the
overlying skin cleaned, and a sterile bandage applied. The patient
was then placed in the left lateral decubitus position as he is unable
to extend his neck. Patient was then tilted head down to shift
contrast into the cervical region. The patient was then transferred
to the CT suite for post myelogram CT study of the cervical spine.

Patient was then transferred to an observation area with appropriate
postprocedural instructions. The patient tolerated the procedure well
without immediate postprocedural complication.

FINDINGS: Myelogram injection performed without difficulty as
described above.

IMPRESSION:
1. Successful myelogram injection. Please see the separate CT report
for discussion of anatomy.
CPT: 62284, 72240-26

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1 comments:

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Anonymous
6 May 2014 at 03:21 delete

good charts for fresher to learn about radiology coding

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