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The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck
Edition 1ISBN: 978-0323430777The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck
Edition 1ISBN: 978-0323430777 Exercise 1
Case 3-1
Interventional radiologists perform both the procedure and the radiologic services, so you will report both the procedure and radiology services.
LOCATION: Outpatient, Hospital
PATIENT: Mike Morgan
PRIMARY CARE PHYSICIAN: Ronald Green, MD
INTERVENTIONAL RADIOLOGIST: Edward Riddle, MD
EXAMINATION: CT-guided liver biopsy.
CLINICAL SYMPTOMS: Liver mass.
CT-GUIDED LIVER BIOPSY: Informed consent was obtained. The patient was placed supine on the CT table, and axial CT was performed to localize the low-density lesion within the dome of the liver medially. The right mid-axillary line skin was prepped and draped in the usual sterile fashion. The skin and subcutaneous tissues were infiltrated with 1% lidocaine. A 19-gauge coaxial needle was advanced into the low-density lesion, and axial CT was performed to confirm needle position prior to biopsy. Four 20-gauge core biopsy samples were obtained. Biopsy samples were obtained using a 20-gauge Monotype biopsy gun. The biopsy gun and coaxial needle were removed.
The patient did not receive conscious sedation. His pulse oximeter and vital signs were monitored throughout the exam. There were no complications. He tolerated the procedure well and left the radiology department in stable condition.
IMPRESSION: Successful and uncomplicated CT-guided biopsy of a low-density mass within the dome of the liver medially.
Pathology Report Later Indicated: Primary malignancy of the liver.
CPT Code(s): _________________
ICD-10-CM Code(s): _________________
Abstracting Questions:
1. What technique was used to accomplish the liver biopsy? _________________
2. What type of radiological guidance was used? _________________
3. Is the radiological guidance reported separately? _________________
4. Was sedation administered? _________________
Interventional radiologists perform both the procedure and the radiologic services, so you will report both the procedure and radiology services.
LOCATION: Outpatient, Hospital
PATIENT: Mike Morgan
PRIMARY CARE PHYSICIAN: Ronald Green, MD
INTERVENTIONAL RADIOLOGIST: Edward Riddle, MD
EXAMINATION: CT-guided liver biopsy.
CLINICAL SYMPTOMS: Liver mass.
CT-GUIDED LIVER BIOPSY: Informed consent was obtained. The patient was placed supine on the CT table, and axial CT was performed to localize the low-density lesion within the dome of the liver medially. The right mid-axillary line skin was prepped and draped in the usual sterile fashion. The skin and subcutaneous tissues were infiltrated with 1% lidocaine. A 19-gauge coaxial needle was advanced into the low-density lesion, and axial CT was performed to confirm needle position prior to biopsy. Four 20-gauge core biopsy samples were obtained. Biopsy samples were obtained using a 20-gauge Monotype biopsy gun. The biopsy gun and coaxial needle were removed.
The patient did not receive conscious sedation. His pulse oximeter and vital signs were monitored throughout the exam. There were no complications. He tolerated the procedure well and left the radiology department in stable condition.
IMPRESSION: Successful and uncomplicated CT-guided biopsy of a low-density mass within the dome of the liver medially.
Pathology Report Later Indicated: Primary malignancy of the liver.
CPT Code(s): _________________
ICD-10-CM Code(s): _________________
Abstracting Questions:
1. What technique was used to accomplish the liver biopsy? _________________
2. What type of radiological guidance was used? _________________
3. Is the radiological guidance reported separately? _________________
4. Was sedation administered? _________________
Explanation
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The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck
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