Medical Coding and Billing

Topics: Liver, Cholesterol, Bile Pages: 5 (968 words) Published: February 23, 2014
1. RADIOLOGY REPORT
LOCATION: Hospital, Outpatient
PATIENT: Dan Diel
ORDERING PHYSICIAN: Daniel G. Olanka, MD
ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD
RADIOLOGIST: Morton Monson, MD
PERSONAL PHYSICIAN: Ronald Green, MD
EXAMINATION: Gallbladder ultrasound.
CLINICAL SYMPTOMS: Increased bilirubin.
GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable. IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.

What is the name of the physician that you are coding for? __________

2. RADIOLOGY REPORT
LOCATION: Hospital, Outpatient
PATIENT: Dan Diel
ORDERING PHYSICIAN: Daniel G. Olanka, MD
ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD
RADIOLOGIST: Morton Monson, MD
PERSONAL PHYSICIAN: Ronald Green, MD
EXAMINATION: Gallbladder ultrasound.
CLINICAL SYMPTOMS: Increased bilirubin.
GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable. IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.

Identify the correct diagnosis (ICD-9-CM) code(s) for the above scenario? ICD-9-CM: __________

3. RADIOLOGY REPORT
LOCATION: Hospital, Outpatient
PATIENT: Dan Diel
ORDERING PHYSICIAN: Daniel G. Olanka, MD
ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD
RADIOLOGIST: Morton Monson, MD
PERSONAL PHYSICIAN: Ronald Green, MD
EXAMINATION: Gallbladder ultrasound.
CLINICAL SYMPTOMS: Increased bilirubin.
GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable. IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.

Using your CPT-4 manual, review the main term in the index and specify what code range the coder is told to review in order to select the appropriate CPT code? ____________________

4. RADIOLOGY REPORT
LOCATION: Hospital, Outpatient
PATIENT: Dan Diel
ORDERING PHYSICIAN: Daniel G. Olanka, MD
ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD
RADIOLOGIST: Morton Monson, MD
PERSONAL PHYSICIAN: Ronald Green, MD
EXAMINATION: Gallbladder ultrasound.
CLINICAL SYMPTOMS: Increased bilirubin.
GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening....
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