Clinical Examples in Radiology (CER) online newsletter is provided for coding professionals to test their knowledge based on review of relevant modern case studies. In this issue learn how to code in the case of a patient with a 25-year history of rheumatoid arthritis (RA), positive rheumatoid factor, and erosions of the bilateral hands who is receiving RA treatment with methotrexate and tocilizumab. Retrospective postprocessing of the microarchitecture (quality) of bone estimation by trabecular bone score (TBS) was requested for the last three dual-energy X-ray absorptiometry (DXA) visits. Apply coding techniques in the case of a 75-year-old male with hematuria and urinary incontinence who is seen to exchange his nephroureteral catheter for a nephrostomy catheter. In the Documentation Challenge, identify the proper codes to report for a patient with a singleton pregnancy of 34 weeks gestation, chronic hypertension, type 2 diabetes, polyhydramnios, and scar from previous cesarean delivery (transverse incision). A transabdominal ultrasound was performed. Size is consistent with dates. All views required for targeted examination attempted; obtained views were documented. Anatomy limited by gestational age and maternal body habitus. Anatomic survey images obtained are within normal limits; no structural anomalies are detected. The radiology test case in this issue highlights the performance of L4-L5 spinal fusion surgery during which four intraoperative lateral views of the lumbar spine were performed portably during the surgery. Dive deeper into these cases and challenge your coding skills with the Fall 2021 issue of Clinical Examples in Radiology.
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The CPT® code set is more than a terminology. It is a system for reimbursement, an enabler of research, a tool for reducing administrative burden and it is a method of accelerating medical innovation.
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