Case
-T3-2B CT SCAN, BRAIN
LOCATION: Outpatient, Hospital
PATIENT: Dianna Evans
PHYSICIAN: Alma Naraquist, MD
RADIOLOGIST: Morton Monson, MD
EXAMINATION OF: CT (computerized tomography) of the brain
CLINICAL SYMPTOMS: Atraumatic subdural hematoma
CT OF THE BRAIN: The exam is significant for extensive subdural fluid accumulation in the left frontoparietal region, extending approximately 3 cm (centimeter) from the inner diploe with associated mass effect causing marked effacement and shift of the left lateral ventricle. There is approximately 1.5 to 2 cm of shift from left to right.
CONCLUSION: Subdural fluid accumulation with mass effect and shift.
Dr. Naraquist was notified, and arrangements were made to have the patient transferred to a tertiary care center for neurosurgery.
T3-2B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): _______________________________________________

Question

Quizplus · Accepted Answer

The Answer is Professional Services: 70450-26 (CT Scan, Without Contrast, Brain)
ICD-10-CM DX: I62.00 (Hemorrhage/hemorrhagic, intracranial, subdural [nontraumatic])
Explanation: The service that was provided is indicated in the Examination section of the report as a CT scan of the brain and reported with 70450 with modifier -26 added to indicate only the professional component was provided.
The Clinical Symptoms indicates the reason for the encounter was an atraumatic subdural hematoma and reported with I62.00. Patient was transferred for continued neurosurgical treatment and care.

Case -T3-2B CT SCAN, BRAIN