Wiki CT Abdomen/Pelvis ??

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Kimberley

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Pt had a CT abdomen/pelvis with performed and returned for a CT abdomen/pelvis without 6 hours later. How should I code this?

Thanks-

Kimberley Tober, CPC
Middleton, WI
 
Why the 2nd exam? There is an MUE of 1 for 74176, 74177, and 74178, so you would have to have good medical necessity to bypass that edit.
If one set was without contrast and the 2nd was with, then you would combine them and code without and with.
 
Reason for the without was to evaluate for interval passage of contrast past the ileocolonic anastomosis.

Findings:
There is redemonstration of dilatation of distal small bowel loops, measuring up to approximately 4.4 cm in diameter. Contrast is now seen within small and large bowel loops, up to the level of the splenic flexure, consistent with interval passage of ingested contrast agent across the ileocolonic anastomosis. Fecalization of distal small bowel at the region of the ileocolonic anastomosis is again noted. A small amount of free intraperitoneal fluid is redemonstrated, with interval distribution.

Excreted contrast agent is seen within the bilateral urinary collecting systems.

The findings of the CT abdomen and pelvis examination are otherwise similar to the most recent CT exam done approximately 6 hours earlier.


IMPRESSION:
Impression:

Redemonstration of dilated and fecalized distal small bowel loops, with interval passage of ingested contrast agent across the ileocolonic anastomosis, consistent with partial small bowel obstruction
 
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