Coding Challenge 4

ABC Hospital

John Doe

Procedure Description– MRI Knee Left W and WO Contrast

Date-June 1, 2018 2:45 pm

Reading Dr-Dr Smith

Exam– MRI Left Knee with and without contrast

Technique– MRI of the left knee performed with and without contrast, 20 cc of IV Dotarem


History– Follow up soft tissue mass within the posterior knee

Findings– Within the posterior knee joint, abutting the PCL, predominately low T1, heterogeneous T2  rounded mass which measures approximately 1.8 x 1x 1.5 image of (TV + AP+ CC) measuring heterogeneous enhancement. No other masses are identified.

No joint effusion

No focal bone marrow edema. No evidence of derangement.

No aberrant tibial artery

Impression– Heterogeneously enhancing soft tissue mass within the posterior knee joint; differential includes a focal area of pigmented villonodular synovitis, intraarticular hemangioma, less likely synovial chondromatosis; would consider follow up MRI of the knee in 3 months to ensure stability.

Signed by Dr Smith 6/1/18 3 pm


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