AAPC - Chapter 17 Practical Applications

CASE 1 Location: Regional Hospital(Performed at the hospital, the radiologist will only code for the professional component.) CT THORAX W/CONTRAST,CT ABDOMEN W/CONTRAST,CT PELVIS W/CONTRAST,Low Osmolar Contrast (Three separate CT scan performed: Thorax (chest), Abdomen, Pelvis) EXAM: CT Chest with Contrast; CT Abdomen with Contrast; CT Pelvis with Contrast August 5, 20XX. COMPARISON: CT chest Regional Hospital 7/8/20XX. HISTORY: Non-small-cell lung cancer. (Pt has non-small cell lung CA.) TECHNIQUE: Axial images of the chest, abdomen pelvis with oral and 125 cc Omnipaque-300 intravenous contrast. (Contrast used.) FINDINGS: Chest CT (Chest CT findings.) shows left upper (Mass is in the left upper lobe.) lobe and pulmonary mass which appear centrally necrotic abutting the posterior pleural surface and mediastinum without definitive invasion, 83 x 64 mm, prior 76 x 56 mm, image 15. Stable lingular and left basilar, right middle lobe and right lower lobe superior segment pleural-parenchymal opacity suggesting scarring. New mild subsegmental infiltrate left upper lobe. No pneumothorax or pleural fluid. No thoracic adenopathy. Heart size normal, no pericardial effusion. Left coronary arteriosclerotic calcification present. No osseous neoplasm. Abdomen CT (Abdomen CT findings.) shows normal liver, gallbladder, biliary ducts, pancreas, spleen, adrenal glands and kidneys. Stomach and duodenum within normal limits. Aortoiliac arterial sclerosis without aneurysm. No retroperitoneal adenopathy. Pelvis (Pelvis CT findings.) CT shows no mass, adenopathy or ascites. No bowel obstruction. No hernia. No osseous neoplasm. Lumbar spine degenerative change present. Left-sided muscle atrophy and brace noted. Conclusion: 1. Increasing size left upper lobe pulmonary mass (The mass is part of the lung CA.) with central cavitation suggested. 2. No thoracic adenopathy or distant metastatic disease demonstrated. 3. Coronary arteriosclerosis. (Secondary diagnosis of coronary arteriosclerosis.)