metzger130
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I am stumped on this and was hoping someone could give me a little help on what I should put for the diagnosis code for this person.
NM-GALLBLADDER 78226\.br\ \.br\CLINICAL INDICATION: The patient is a 59-year-old male with a history of laceration of the liver and gallbladder 3/20/2013 with subsequent abdominal abscess and drainage is referred for interval evaluation of hepatobiliary function.\.br\ \.br\COMPARISON: HIDA study 11/13/2013, CT of the abdomen/pelvis 1/13/2014, 1/1/2014\.br\ \.br\TECHNIQUE: The patient was administered 5.0 mCi of Tc-99m labeled Choletec intravenously followed by dynamic imaging over the abdomen for 60 minutes. Additional delayed static images of the abdomen and pelvis were acquired in multiple views approximately \.br\2.5 hours post injection, including upright and left lateral decubitus positioning.\.br\ \.br\ \.br\FINDINGS: There is normal uptake and clearance of the radiotracer by the liver parenchyma. The photopenic defect is seen in the dome of the liver corresponding to the hypodensity seen on CT. Activity appears within the GI tract by 23 minutes post \.br\injection. Similar to the prior study, there is visualization of a small gallbladder approximately 50 minutes post injection. There is no evidence of abnormal biliary extravasation to suggest an active biliary leak. \.br\ \.br\ \.br\Normal study. \.br\1. No evidence for bile leak.\.br\2. Normal liver function. \.br\3. A photopenic defect is seen in the dome of liver corresponding to the hypodense lesion seen on CT which is of uncertain etiology. The lack of radiotracer activity within the region is consistent with the absence of normal functioning liver parenchyma \.br\within this lesion.\.br\4. Patent biliary tract.
Thanks for any help,
Rob
NM-GALLBLADDER 78226\.br\ \.br\CLINICAL INDICATION: The patient is a 59-year-old male with a history of laceration of the liver and gallbladder 3/20/2013 with subsequent abdominal abscess and drainage is referred for interval evaluation of hepatobiliary function.\.br\ \.br\COMPARISON: HIDA study 11/13/2013, CT of the abdomen/pelvis 1/13/2014, 1/1/2014\.br\ \.br\TECHNIQUE: The patient was administered 5.0 mCi of Tc-99m labeled Choletec intravenously followed by dynamic imaging over the abdomen for 60 minutes. Additional delayed static images of the abdomen and pelvis were acquired in multiple views approximately \.br\2.5 hours post injection, including upright and left lateral decubitus positioning.\.br\ \.br\ \.br\FINDINGS: There is normal uptake and clearance of the radiotracer by the liver parenchyma. The photopenic defect is seen in the dome of the liver corresponding to the hypodensity seen on CT. Activity appears within the GI tract by 23 minutes post \.br\injection. Similar to the prior study, there is visualization of a small gallbladder approximately 50 minutes post injection. There is no evidence of abnormal biliary extravasation to suggest an active biliary leak. \.br\ \.br\ \.br\Normal study. \.br\1. No evidence for bile leak.\.br\2. Normal liver function. \.br\3. A photopenic defect is seen in the dome of liver corresponding to the hypodense lesion seen on CT which is of uncertain etiology. The lack of radiotracer activity within the region is consistent with the absence of normal functioning liver parenchyma \.br\within this lesion.\.br\4. Patent biliary tract.
Thanks for any help,
Rob