AAPC - Chapter 17 Practical Applications with
expert interventions (Guaranteed Success)
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 basila - answer 74177-26, 71260-26, C34.12, I25.10
CASE 2
, Location: Independent Diagnostic Testing Facility, radiologist employed by the facility.
(Radiologist is employed by the facility, the IDTF will bill for global component.)
CT BRAIN/HEAD W/WO CONTRAST EXAM: CT Head, without and with Contrast August 5, 20XX.
COMPARISON: None available.
HISTORY: Non-small-cell lung cancer. (Patient has non-small cell lung cancer, not specified to
location in lung.)
TECHNIQUE: Axial images of the calvarium without and with (CT performed without and with
contrast.) 125 cc Omnipaque-300 intravenous contrast. (Contrast was intravenous.)
FINDINGS: The calvarium is intact. Imaged upper portions of the maxillary antra show minimal
mucosal thickening. The sphenoid ethmoid and frontal sinuses are clear bilaterally. No
hydrocephalus, mass effect, brain shift, abnormal extra-axial fluid collection or mass.
Calcification left basal ganglia without mass effect, nonspecific, likely ben - answer 70470,
C34.90, I67.2, G93.9, G23.8
CASE 3
Location: Imaging center; radiologist employed.(Radiologist is employed by the imaging center:
the imaging center should report the global component.)
STUDY: MAMMOGRAM BILATERAL SCREENING,(Screening bilateral mammogram.) all VIEWS,
PRODUCING DIRECT DIGITAL IMAGE
REASON: SCREEN
expert interventions (Guaranteed Success)
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 basila - answer 74177-26, 71260-26, C34.12, I25.10
CASE 2
, Location: Independent Diagnostic Testing Facility, radiologist employed by the facility.
(Radiologist is employed by the facility, the IDTF will bill for global component.)
CT BRAIN/HEAD W/WO CONTRAST EXAM: CT Head, without and with Contrast August 5, 20XX.
COMPARISON: None available.
HISTORY: Non-small-cell lung cancer. (Patient has non-small cell lung cancer, not specified to
location in lung.)
TECHNIQUE: Axial images of the calvarium without and with (CT performed without and with
contrast.) 125 cc Omnipaque-300 intravenous contrast. (Contrast was intravenous.)
FINDINGS: The calvarium is intact. Imaged upper portions of the maxillary antra show minimal
mucosal thickening. The sphenoid ethmoid and frontal sinuses are clear bilaterally. No
hydrocephalus, mass effect, brain shift, abnormal extra-axial fluid collection or mass.
Calcification left basal ganglia without mass effect, nonspecific, likely ben - answer 70470,
C34.90, I67.2, G93.9, G23.8
CASE 3
Location: Imaging center; radiologist employed.(Radiologist is employed by the imaging center:
the imaging center should report the global component.)
STUDY: MAMMOGRAM BILATERAL SCREENING,(Screening bilateral mammogram.) all VIEWS,
PRODUCING DIRECT DIGITAL IMAGE
REASON: SCREEN
