Wiki CTA WITH DYNAMIC AIRWAYS STUDY....CORRECT CODING

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margaret fahy

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CTA WITH DYNAMIC AIRWAYS STUDY....SOMEONE PLEASE!​

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margaret fahy​

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Should the code be 71275 only, or should 71250 (59) also be coded?

CT ANGIOGRAPHY CHEST
DYNAMIC AIRWAY CT

INDICATION: Evaluation for aortopexy in the setting of
tracheobronchomalacia; Hamilton Protocol


TECHNIQUE: CT angiography of the chest was performed using
ECG-triggered dual source, high pitch Cardiac FLASH technique.
Intravenous contrast was administered. Delayed images were not
obtained.

Dynamic airway CT was performed using cine CT technique. A 4 cm
field of view was placed over the area of interest and the CT was
performed over 1 to 2 respiratory cycles. Low dose technique was
utilized.

Images were reconstructed in axial, coronal, and sagittal planes.

3-D images were generated on an independent workstation for
better demonstration of cardiovascular and airway structures.

PATIENT EVENTS: None reported.

The patient's weight is 12.5 kg and the patient's height is 84
cm.
The calculated BSA is 0.5 m2.

CTA FINDINGS:
AORTA: Ascending aorta normal in size. There is a left arch with
common origin of the brachiocephalic and left common carotid
arteries, a normal variant.
Aorta percentage anterior to the anterior border of the spine at
level of LMSB: 25-49%
ARTERY OF ADAMKIEWICZ: Not clearly identified though noting the
anterior spinal artery is best seen at the level of L1. Note, it
is also not visible on the prior study dated 2/24/2021.

PULMONARY ARTERIES: Normal course and caliber.
SYSTEMIC AND PULMONARY VEINS: Normal connections, unobstructed.
DUCTUS ARTERIOSUS: None identified.
HEART: Moderate enlargement of the right atrium.

PERICARDIUM: No effusion.
PLEURAL SPACE: No effusion or pneumothorax.

AIRWAY: Patent. Tracheostomy terminates above the carina. See
below for dynamic evaluation.
LUNGS: A 2 mm pulmonary nodule in the right lower lobe (series 7,
image 30), likely inflammatory. Right lower lobe linear
atelectasis.
MEDIASTINUM: No mediastinal or hilar lymphadenopathy.
UPPER ABDOMEN: Gastrostomy tube.
BONES/SOFT TISSUES: Partial rib fusions noted.

DYNAMIC AIRWAY FINDINGS:
Number of Segments acquired: 1
Ventilatory Support: Tracheostomy/CPAP
PEEP setting: 8 cm H2O
PEEP adjusted: N/A
Tracheobronchomalacia: None, specifically there is no dynamic
collapse at the level of the left mainstem bronchus as it passes
anterior to the aorta.
LMSB Collapse : 0-24%
External compression: No
Other comments: None


IMPRESSION:
1. Aorta anatomy as above.
2. Artery of Adamkiewicz not clearly identified.
3. No evidence of tracheobronchomalacia during dynamic
evaluation.

Last edited: Wednesday at 5:16 AM
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