Case
-T3-2A CT SCAN, SINUSES
LOCATION: Outpatient, Hospital
PATIENT: Lillian Parker
PHYSICIAN: Ronald Green, MD
RADIOLOGIST: Morton Monson, MD
EXAMINATION OF: CT (computerized tomography) of sinuses
CLINICAL SYMPTOMS: Chronic sinus infection with change in
mental status
COMPUTED TOMOGRAPHIC EXAMINATION OF THE PARANASAL SINUSES was performed utilizing thin axial images computed for high-resolution bone algorithm 3-D. Apparently direct coronal images could not be obtained. Therefore, coronal reconstructions were performed from the original data set. The study was performed under my supervision and is presented to me today for evaluation. Independent work station not required.
Frontal sinuses are well aerated. There may be some mucosal thickening at the base of each frontal sinus.
Most of the ethmoid sinuses show mucosal thickening. Several ethmoid sinuses are filled with abnormal soft-tissue density, although most ethmoid sinuses are at least partially aerated.
Bilaterally, the sphenoid sinuses show a considerable amount of mucosal thickening. Right sphenoid sinus is larger than the left. It is possible that there may be fluid level within either of the sphenoid sinuses.
Bilaterally, the maxillary sinuses show mucosal thickening, particularly posteriorly. I cannot comment about the drainage pathways of the maxillary sinuses. Unfortunately, there is movement artifact in the images, and this causes considerable misregistration of the coronal reconstructions.
There is a nasal airway inserted on the right.
I believe the right middle turbinate has most probably been surgically removed in the past. There may be surgically created small patency connecting the left middle meatus and the left maxillary sinus on image 19.
I do not appreciate overt bone erosion. It is presumed that the findings represent inflammatory change.
T3-2A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question

Quizplus · Accepted Answer

The Answer is Professional Services: 70486-26 (CT Scan, without Contrast, Face), 76376-26 (CT Scan,
3D Rendering)
ICD-10-CM DX: J32.9 (Sinusitis, [chronic]), R41.82 (Change(s) [in] mental status)
Explanation: The report indicates the radiology service was a CT scan, without contrast, of the face and reported with 70486 with modifier -26 added to indicate only the professional service was provided. The first paragraph of the report indicated "Therefore, coronal reconstructions were performed from the original data set." The reconstruction is reported separately with 76376.
The Clinical Symptoms section of the report indicated chronic sinus infection and change in the mental status as the reasons for the encounter and reported with J32.9 and R41.82. Altered mental status should always be reported.

Case -T3-2A CT SCAN, SINUSES