mbdk1977
Networker
Hi, I have seen multiple postings here for an MRI of the Brachial Plexus, I'm curous to see how you would code this example...
MRI UP EXT RT NOT JOINT W/WO
HISTORY:
Axillary mass, radial nerve compression.
Right brachial plexus MRI with and without contrast.
PROCEDURE:
Coronal T1, coronal STIR, sagittal T2, sagittal T1, axial T2, axial T1, and axial sagittal and coronal T1 post-contrast imaging was obtained of the right brachial plexus.
14 mL of gadolinium was used.
FINDINGS:
There appear to be mild degenerative changes of the right shoulder. There is otherwise normal signal within the bone marrow. The right brachial plexus is normal with normal appearing vessels, nerve roots and fat. No mass is identified aside from an unremarkable appearing lymph node. The surrounding muscles and soft tissues are otherwise unremarkable.
There are no abnormal areas of enhancement.
IMPRESSION:
Unremarkable MRI of the right brachial plexus. Incidentally, the limited images of the cervical spine demonstrate multilevel degenerative changes with disk osteophyte complex. The cord appears grossly unremarkable.
MRI UP EXT RT NOT JOINT W/WO
HISTORY:
Axillary mass, radial nerve compression.
Right brachial plexus MRI with and without contrast.
PROCEDURE:
Coronal T1, coronal STIR, sagittal T2, sagittal T1, axial T2, axial T1, and axial sagittal and coronal T1 post-contrast imaging was obtained of the right brachial plexus.
14 mL of gadolinium was used.
FINDINGS:
There appear to be mild degenerative changes of the right shoulder. There is otherwise normal signal within the bone marrow. The right brachial plexus is normal with normal appearing vessels, nerve roots and fat. No mass is identified aside from an unremarkable appearing lymph node. The surrounding muscles and soft tissues are otherwise unremarkable.
There are no abnormal areas of enhancement.
IMPRESSION:
Unremarkable MRI of the right brachial plexus. Incidentally, the limited images of the cervical spine demonstrate multilevel degenerative changes with disk osteophyte complex. The cord appears grossly unremarkable.