Please code the ICD-10-CM code and the CPT. Do not code external cause codes.
Name: Jane Doe
Reading Dr. Dr Smith
Jan 1, 2018–3:00 pm
Exam- CT Cervical Spine WO Contrast
Study- Ct Cervical Spine WO Contrast
History-Trauma to neck. MVA
Axial unenhanced CT images of the cervical spine were obtained, no comparison images are available. There are 7 cervical type vertebral bodies which are maintained in height. There is reversal of the normal cervical lordosis. Posterior elements are intact. Atlantoaxial and atlantooccipal articulations are maintained. There is some rotation at the C1-C2 articulation which limits evaluation but it within normal limits.
Impression- No acute traumatic abnormality of the cervical spine.
I agree with the above findings-
Signed Dr Smith 3:30 pm 1/1/18
*Please note this is not a real report and does not contain real data. It is compliant with HIPAA laws.