CASE #1:

REASON FOR STUDY: cbd stones

MODALITY: HMN OEC ERCP C-ARM

NARRATIVE:
Several spot digital radiographs of right upper quadrant were performed during an ERCP and submitted following the procedure. There is faint visualization of the bile ducts as well as the main pancreatic duct. There is a suggestion of dilatation of the main pancreatic duct centrally. A balloon catheter seen with the balloon inflated in the distal common bile duct on one of the radiographs. These radiographs are available for review by gastroenterology. Fluoroscopy time is documented 147.1 seconds.

IMPRESSION:

DIAGNOSIS:

ADMITTING DIAGNOSIS:
6216:K85.9: Acute pancreatitis
Apply PQRS Medicare patient

**I have the following:
CPT: 43260 (didn’t charge for fluoroscopy because according to what I read for guidelines this is already included with code)
DX: K85.9
HCPCS/PQRS: G9500
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CASE #2:

Technique: MR examination of the pelvis with attention to the prostate is performed on a 3 Tesla magnet before and after contrast administration using standard pulse sequences. Dynamic multiphasic imaging through the prostate is performed following contrast administration, with evaluation of pharmaco-kinetics and diffusion weighted sequencing performed on a separate workstation.

Priors: None

FINDINGS: The prostate is not enlarged, measuring 4.0 x 3.0 x 2.8 cm with a volume of 16.9 cc. The seminal vesicles appear unremarkable. The ejaculatory ducts appear normal. There is a focal fingerlike nodule protruding off of the median lobe into the midline bladder base measuring 0.9 x 1 x 1.8 cm. The peripheral zone demonstrates generalized hazy diminished signal intensity without evidence of focal abnormality. The prostate capsule is well demarcated. There is mild generalized hyperemia present. The possibility of chronic prostatitis cannot be excluded and clinical correlation is recommended. No abnormal diffusion or perfusion is seen. No pelvic lymphadenopathy is appreciated. No osseous abnormality is seen.

IMPRESSION:

1. No evidence of prostate enlargement. Fingerlike protrusion of the median lobe of the prostate into the bladder base in the midline.
2. Hazy low signal intensity within the peripheral zone which demonstrates generalized hyperemia. Chronic prostatitis cannot be excluded. No MR findings to suggest prostate neoplasm.

DIAGNOSIS:
Enlarged prostate with lower urinary tract symptoms

**I have the following:
CPT: 72197
DX: N40.1, R68.89
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CASE #3:

NARRATIVE:
Clinical Statement: Leukemia and new onset chest pain.

Technique: CT angiogram of the chest was performed with intravenous contrast following a pulmonary embolism protocol. Coronal reformatted maximum intensity projections were obtained.

Compared to 7/16/2015 CT chest.

Findings: Assessing for pulmonary emboli is difficult secondary to respiratory motion. No gross central pulmonary emboli detected.

A left pacemaker is stable. It is attached electrodes ending in the right atrium and right ventricle, unchanged.

1.5 cm low-density calcified right thyroid nodule is stable. No mediastinal adenopathy is present. For example a subcarinal lymph node currently measuring 3.4 x 1.3 cm previously measured 3.5 x 1.3 cm. Mild hilar adenopathy is also stable. No axillary adenopathy has developed. Mild cardiac enlargement is stable. No significant pericardial effusion is detected. Mild to moderate atherosclerotic calcifications of coronary arteries are stable. Small bilateral pleural effusions are
present. The left is smaller than on the prior study. The right is stable. Compressive atelectasis of roughly 10% right lower lobe of the lung is stable. Compressive atelectasis at the left lung base is
improved and is now roughly 10%. New consolidations are present in the right middle lobe medial segment measuring 3.3 x 3.1 cm and the lingual measuring 4.6 x 2.9 cm. Worsening groundglass infiltration is present throughout the rest the lungs. There is a few other new patchy opacities in the right upper lobe which are small in volume.

No suspicious osseous lesions detected in the thorax.

No new focal abnormalities detected in the lies upper abdomen.

IMPRESSION:

1. No acute central pulmonary emboli.
2. New moderate zones of consolidation in the lungs in the right middle lobe and lingula which may reflect pneumonia in the correct clinical setting. Worsening groundglass infiltrates which may reflect infection or edema.
3. Stable right pleural effusion and adjacent lung posterior atelectasis. Slight decrease size left pleural effusion with decreased left lower lung atelectasis.
4. Stable mediastinal and hilar adenopathy.

DIAGNOSIS:

ADMITTING DIAGNOSIS:
293411:D70.9: Neutropenic fever
 
**I have the following:
CPT: 71275
DX: D70.9, C95.90, J91.0, J98.11, R59.0
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CASE #4:

Clinical: 60-year-old man presents for restaging of mantle cell lymphoma

PROTOCOL INFORMATION:

Ninety minutes following the intravenous administration of 14.2 millicuries of F-18- fluorodeoxyglucose, a dedicated PET scan was performed from the skull base to upper thighs in the transaxial, coronal, and sagittal planes, as well as with rotating MIP format. The scan was performed with the patient in the fasting state both with and without CT attenuation correction.

With the patient in the same position a low dose CT scan was also performed. Interpretation of this examination was made by evaluation of both the anatomic (CT) and metabolic (PET) data which were electronically fused.

An accompanying optimized contrast-enhanced CT scan was also requested and performed. A full interpretation of this CT scan is reported separately.

PET/CT FINDINGS:

Direct comparison is made with a prior PET/CT dated 8/22/2015

Current study demonstrates no focus of abnormal hypermetabolism within the neck or chest to suggest a site of pathologic lymphadenopathy. Mild hypermetabolism within the palatine tonsil and lingual tonsil is within physiologic limits. Below the diaphragm there is normal distribution trace throughout the liver and spleen. There is normal excretion of contrast from the kidneys bilaterally. Nonspecific bowel activity is seen. No focus of abnormal activity seen within the retroperitoneum or pelvis to suggest a site of pathologic lymphadenopathy.

IMPRESSION:

No significant change from prior study of 8/22/2015. No focus of abnormal activity seen in the neck, chest, abdomen, or pelvis to indicate a site of pathologic lymphadenopathy.

DIAGNOSIS:
Mantle cell lymphoma, extranodal and solid organ sites

Apply PI or PS modifier: Medicare patient

**I have the following:
CPT: 78815-26-PS, A9552
DX: C83.19
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CASE #5:

History: Chest pain.

Technique: Pharmacological Myoview SPECT myocardial perfusion scan was performed in the horizontal and vertical long axis, short axis, and transaxial projections using Myoview one-day protocol. Images at stress were obtained after injection of 25 mCi Myoview and at rest after injection of 12 mCi of Myoview. A one day protocol was employed. There was no report of chest pain and EKG findings were reported as negative by the monitoring cardiologist.

Comparison: None.

Findings: Evaluation of the resting images demonstrates physiologic tracer distribution. There is normal wall motion and thickening on gated images. The calculated ejection fraction is greater than 60% indicating normal systolic function.

Evaluation of the stress images demonstrates a similar pattern of tracer distribution. No reversible perfusion abnormalities are noted.

IMPRESSION:

1. No evidence of pharmacologically-induced ischemia.

2. Normal systolic function with calculated ejection fraction of greater than 60%.

**I have the following:
CPT: 78451
DX: R07.9

(this scenario I really struggled with because I RARELY code nuclear medicine)

Any help anyone could provide on the above scenarios would be greatly appreciated, I’ve been reviewing / studying guidelines daily but these few have me stumped.