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 40-year-old female with a noncalcified oval mass with circumscribed margins in the right breast at the 6 o'clock position at anterior depth detected on a baseline screening mammography with digital breast tomosynthesis. Right breast ultrasound is recommended for further evaluation. Apply coding techniques in the case of a 57-year-old male with a history of hypertension, hyperglycemia, hypercholesterolemia, and body mass index (BMI) of 31.6 kg/m2 (ie, metabolic syndrome) with an elevated liver function enzyme level (alanine aminotransferase of 65 U/L). A right upper quadrant abdominal ultrasound showed evidence of hepatic steatosis. The patient is referred for abdominal magnetic resonance imaging (MRI) with quantitative multiparametric magnetic resonance (mp-MR) evaluation to assess for steatohepatitis. In the documentation challenge, identify the proper codes to report for a patient with coronary artery atherosclerosis and chest pain who is referred for CT angiography heart with contrast, and three-dimensional (3D) with quantitative coronary plaque analysis (QCA). The radiology test case in this issue highlights the performance of injection of disc tissue allograft at L3-L4. Dive deeper into these cases and challenge your coding skills with the Winter 2022 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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