Chapter 17 Practical Application (Case 6-10)

CASE 10 Location: Regional Hospital TYPE OF PROCEDURE: 1. Abdominal aortic angiogram 2. Mesenteric artery angiogram HISTORY: Mesenteric ischemia. INFORMED CONSENT: The procedure was discussed with the patient and his wife. The risks, including bleeding, infection and vascular injuries such as dissection, perforation, thrombus, and embolus were outlined. Informed consent was obtained. CONTRAST: 123 ml Ultravist 370. DESCRIPTION OF PROCEDURE: The patient's right groin was sterilely prepped and draped. The skin and subcutaneous tissues were anesthetized with 2% lidocaine. The right common femoral artery was then percutaneously accessed and a wire advanced into the abdominal aorta under fluoroscopic visualization. A 5-French vascular sheath was placed into the right groin. An Omni Flush catheter was advanced to the upper abdominal aorta. Digital subtraction angiography of the abdominal aorta was performed. It demonstrates mild tortuosity of the aorta. The caliber is normal. A single renal artery is seen bilaterally without stenosis. The common iliac vessels are patent. The Omni Flush catheter was then exchanged for a Cobra 2 catheter. The superior mesenteric artery was then selectively catheterized. Digital subtraction angiography was performed in multiple obliquities. The origin is patent. No focal stenosis or branch occlusions are identified. Next, the celiac artery was selectively catheterized. Digital subtraction angiography was performed in 2 obliquities. The origin is normal. No focal stenosis or branch occlusions are present. Next, attempts were made to catheter the inferior mesenteric artery with the Cobra 2 catheter. This was unsuccessful. Selective catheterization of the inferior mesenteric artery was achieved with a Simmons 2 catheter. Digital subtraction angiography was then performed in 2 obliquities. The origin is patent. No stenosis or branch occlusions are present. The Simmons 2 catheter was removed as was the right groin sheath over a wire. Hemostasis in the right groin was then achieved using an Angio-Seal closure device. IMPRESSION: Normal abdominal aortic angiogram and mesenteric angiogram of selective catheterization of the celiac, superior mesenteric and inferior mesenteric arteries. What are the CPT® and ICD-10-CM codes reported for this service? CPT® codes: [a], [b], [c], [d], [e], [f] ICD-10-CM code: [g]

36245, 36245-59, 36245-59, 75726-26, 75726-26-59, 75726-26-59, K55.9

CASE 6 Location: Regional Hospital Fluoro Hysterosalpingogram EXAMINATION: HYSTEROSALPINGOGRAM (PROCEDURE PERFORMED 8Y RADIOLOGIST) INDICATION: Infertility for 15 years. Patient had one child 15 years ago. Last menstrual period was 1/13/20XX. No history of pelvic infection or surgery COMPARISON: None PROCEDURE: The examination and anticipated discomfort was discussed with the patient. A plastic vaginal speculum was introduced with the patient's legs in the stirrups following preliminary vaginal examination and lubrication. The posterior vaginal fornix and outer cervical os were prepped with a cleansing solution. A 5F hysterosalpingogram catheter was used. The catheter balloon was inflated in the lower uterine segment. Fluoroscopic and radiographic assessments were done. The patient tolerated the procedure well. FINDINGS: Contrast was administered through the catheter and multiple images were taken. There is a possible abnormal contour to the right cornua with patchy contrast opacification which may represent intramural contrast with intravasation. No definite spillage of contrast from either fallopian tube was identified IMPRESSION: 1. Possible right cornual contour abnormality manifested by focal extravasation and minimal intravasation of undetermined etiology. Recommend endovaginal ultrasound for further evaluation. 2. No contrast filling of either tubes and no spill into pelvic peritoneal space. What are the CPT® and ICD-10-CM codes reported for this service? CPT® codes: [a], [b] ICD-10-CM code: [c]

58340, 74740-26, N97.9

CASE 7 Location: Regional Hospital CT THORAX W/CONTRAST,CT ABDOMEN W/CONTRAST,CT PELVIS W/CONTRAST,Low Osmolar Contrast 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. TECHNIQUE: Axial images of the chest, abdomen pelvis with oral and 125 cc Omnipaque-300 intravenous contrast. FINDINGS: Chest CT shows left upper 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 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 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 with central cavitation suggested. 2. No thoracic adenopathy or distant metastatic disease demonstrated. 3. Coronary arteriosclerosis. What are the CPT® and ICD-10-CM codes reported for this service? CPT® codes: [a], [b] ICD-10-CM codes: [c], [d]

74177-26, 71260-26, C34.12, I25.10

CASE 9 Location: Regional Hospital EXAMINATION: 1. CT ENTEROCLYSIS (FLUORO ENTEROCLYSIS WITH CT ABDOMEN - NEUTRAL ENTERAL WITH IV CONTRAST- 2D REFORMATS) 2. CT ENTEROCLYSIS (FLUORO ENTEROCLYSIS WITH CT PELVIS - NEUTRAL ENTERAL WITH IV CONTRAST - 20 REFORMATS) Clinical Indication: Unexplained abdominal pain and diarrhea, as well as weight loss. Normal colonoscopy. Comparison: None. PROCEDURE: In accordance with policy and procedure standard medication reconciliation was performed by the radiologic technologist prior to IV contrast administration. No contraindication was identified. The examination was performed in accordance with the standard protocol on a 43-year-old male. Following preprocedure assessment, informed consent was obtained. Conscious sedation Independent observation performed by Amy Smith, RN. Total Time of Sedation: 60 minutes. Vital signs, pre-procedureand post-procedure monitoring were done by nurse in attendance with me performing the conscious sedation. A transnasal intubation was done following a nasal drop of a local anesthetic. Under fluoroscopic guidance, using guidewire and positional maneuvers, the enteroclysis catheter was advanced and the tip anchored at the distal horizontal duodenum. Neutral enteral contrast was infused and monitored to a total of approximately 3.5 L. 0.6 mg Glucagon was administered IV prior to IV contrast administration. CT acquisition was done during continued infusion of enteral contrast following a 45 to 50 seconds delay. Intravenous administration of 100 ml lsovue 370 at 4 ml/second infusion rate. CT parameters used were 40 x 0.625 mm collimation reconstructed at 2 mm section thickness reconstructed at 1 mm intervals. The source images were transferred to an independent workstation (EBW) and cross referenced multiplanar interactive 2D interpretation was done by the radiologist. Images were reviewed using soft tissue window settings. Following completion of the infusion, the catheter was withdrawn into the stomach and refluxed contrast removed prior to catheter removal. No acute adverse events occurred. FINDINGS: There is no evidence of transmural inflammatory disease changes involving the small bowel or the colorectum. There is, however, mild prominence of the vasa recta in the right lower abdomen, mild increased attenuation of the cecum and ascending colon and adjacent distal small bowel. Suggest biopsy at the ascending colon to exclude microscopic colitis. If the patient has a history of blood in the stools, air double-contrast enteroclysis would be of value to exclude aphthous ileitis. CT enteroclysis may not be able to assess for early Crohn's until transmural involvement is seen. The rest of the colon also appears normal. There are no fold changes to suggest adult celiac disease. There is no evidence of a small bowel mass. The mesentery appears normal. Solid abdominal organs are grossly unremarkable. IMPRESSION: 1. No evidence of transmural inflammatory disease changes involving the small bowel or colorectum. No fold abnormalities to suggest sprue. 2. Prominence of vasa recta of cecum and ascending colon and distal ileum with question of mild increased attenuation. Consider microscopic colitis. See discussion and recommendation above. If there is strong clinical suspicion of Crohn's disease, consider air DC barium enteroclysis to exclude or confirm early aphthoid changes. 3. Reproduction of abdominal pain during contrast infusion, thus, correlated for visceral hypersensitivity. 4. Solid abdominal organs grossly unremarkable. What are the CPT® and ICD-10-CM codes reported for this service? CPT® codes: [a], [b], [c], [d], [e] ICD-10-CM codes: [f], [g], [h]

74177-26, 74340-26, 44500, 99152, 99153 x 3, R10.9, R19.7, R63.4

CASE 8 Location: Regional Hospital EXAM: Renal and bladder ultrasound dated 10/01/20XX Renal artery Doppler evaluation dated 10/01/20XX COMPARISON: Renal MRA dated 04/01/20XX HISTORY: 80-year-old with renal artery stenosis. Diagnostic ultrasound of the kidneys was ordered to see if there was kidney damage due to the renal stenosis or other kidney issues. This was followed after review with a renal Doppler study. FINDINGS: Multiple grayscale sonographic and color Doppler images of the kidneys and renal vasculature were submitted for interpretation. The right kidney measures 10.1 cm without evidence of pelvic caliectasis. There is a small 8mm cyst noted within the lower pole of the right kidney. There is relatively normal internal architecture and echogenicity. The left kidney measures 10.4 cm with no evidence of pelvicaliectasis. There are at least 3 renal cysts identified, the largest measuring 2 cm in diameter. There is normal internal architecture and echogenicity. The bladder is distended with urine and appears within normal limits. The aorta demonstrates peak systolic velocity of 1.07 m/sec. The right renal artery origin demonstrates peak systolic velocity of 3.0 m/sec with a resistive index of 0.92. The midportion of the right renal artery demonstrates a peak systolic velocity of 1.1 m/sec with resistive index of 0.8. The right renal hilum has a peak systolic velocity of 0.64 m/sec with resistive index of 0.85. The inferior pole has a systolic velocity of 0.16 m/sec with resistive index of 0.54. The midpole has a systolic velocity of 0.18 m/sec and resistive index of 0.70. The superior pole has a velocity peak of 0.22 m/sec with a resistive index of 0.77. The left renal artery origin demonstrates a peak systolic velocity of 2.0 m/sec with a resistive index of 0.87. The mid portion of the left renal artery demonstrates a peak velocity at 0.42 m/sec and a resistive index of 0.80. The left renal hilum has a peak systolic velocity of 0.47 m/sec and a resistive index of 0.82. The inferior pole has a systolic velocity of 0 16 m/sec and a resistive index of 0.67. The midpole has a systolic velocity of 0.17 m/sec and a resistive index of 0.63. The superior pole has a velocity peak of 0.13 m/sec with a resistive index of 0.69. IMPRESSION: RENAL ARTERY DOPPLER STUDY: 1. Moderate stenosis of the right renal artery origin. 2. Mild to moderate left renal artery origin stenosis. RENAL AND BLADDER ULTRASOUND: 1. Bilateral probable renal cysts. 2. Normal appearing bladder What are the CPT® and ICD-10-CM codes reported for this service? CPT® codes: [a], [b] ICD-10-CM code: [c]

93976-26, 76770-26-59, I70.1