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coding challenge

Coding Challenge 7

ldellavella

Please code the CPT and ICD-10-CM code for this report. This report is HIPAA compliant and does not contain PHI.

 

Exam- Right hip including pelvis 2-3 views

Date- June 4, 2018

#1111222222

Exam-Hip x-ray right including pelvis 2-3 views

Clinical History- Right hip pain

Comparison- hip x ray 2/4/17

Technique- 2 views of the right hip and 1 ap view of the pelvis was performed

Findings: Pelvis ring intact. The sacroiliac joints are symmetric. No right hip fracture or dislocation. Punctate ossific density adjacent to the right hip. Left hip unremarkable.

Soft tissue- normal

Impression:

No right hip fracture or dislocation. Punctate ossific density adjacent to the right hip most likely related to degenerative changes.

 

Thank you for referring your patient.

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coding challenge

Coding Challenge 6

ldellavella

Please read the report below and code the CPT and the ICD-10-CM Code. Please keep in mind that these reports are designed to be as realistic as possible, but everything is HIPAA compliant so the information is not real.

*For the tomo, please use the HCPCS code.

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Procedure- Bilateral Diagnostic Mammogram with Tomo

History- Bilateral breast pain for 2 weeks

Technique- Full field mammography was performed. Bilateral breast tomosynthesis was preformed in the MLO and CC projections. CAD was used as an aid for interpreting this exam.

Comparison: Prior mammo from April 2017

Density- There are scattered fibroglandular densities

Findings: There is no suspicious mass, microcalcifications,  or unexplained distortions.

Impression: No dominant mass or secondary signs of malignancy within either breast. Annual screenings recommended. BIRADS ASSESSMENT- (2) Benign findings.

Signed Dr. J.

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coding challenge

Coding Challenge 5

ldellavella

Please code the ICD-10-CM and CPT code for this report. To check your answers, click the link at the bottom of the report.

ABC Hospital

Patient Name- Jon Doe

Date- 1/1/18

Referring Dr- Dr Smith

Exam- US Renal

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Procedure- US Renal

History- Routine check of renal cysts

Technique-2D images

Findings- Complete evaluation of the right kidney. Right kidney is normal in size with no hydronephrosis. No calculus. Simple cyst measuring 1.4 x 2.1 x 3.6 located mid portion. Simple cyst #2 measuring 1.7x 1.9 x 1.6 located upper pole.

RT kidney retroperitoneal measurements- length 9.71 AP 5.04 cm. width 5.52 cm

Complete evaluation of the left kidney. The kidney is normal in size with no hydronephrosis. Complex cyst measuring 2.2x 1.2x 1.5 located mid portion. Visualized portion of the IVC are normal. Proximal and abdominal aorta obscured by bowel gas.

LT kidney retroperitoneal measurements- length 11.50 cm AP width 6.25 cam

The bladder is normal.

Prostate is normal.

Impression- No hydronephrosis. Bilateral renal cysts.

Signed by Dr Michaels 4:00 pm 1/1/18

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