Mets Liver and lung

troupe327

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I am having extreme difficulty coding this as I have never seen this type of case before.

Begin report****
Reason For Exam
COLANGIOCARCINOMA
REPORT
CT CHEST, ABDOMEN AND PELVIS

REASON FOR EXAMINATION: Cholangiocarcinoma.

COMPARISON: Previous studies, the most recent from 1/21/2012

Multiple axial images were obtained from the thoracic inlet to the ischial
tuberosities following administration of Omnipaque oral contrast and 70 cc of
Isovue-370 intravenously.

Lungs and pleura: Numerous small pulmonary nodules are now more conspicuous
bilaterally with the largest nodules in the right lung base measuring up to 5
mm in size. No acute focal infiltrates are seen. There is no pleural effusion
or pneumothorax.

Mediastinum and hila: No enlarged mediastinal or hilar lymph nodes are seen.
There is a 1.1 x 0.8 cm precarinal node that is a identified and appears more
prominent than on the previous study. The trachea and mainstem bronchi are
patent. The heart is normal in size. There is no pericardial effusion.

Axilla: No adenopathy is identified.

Liver: Numerous ill-defined low-attenuation masses have increased in number
and are more conspicuous in the anterior aspects of the right and left hepatic
lobes. Irregular confluent mass within the liver around the falciform ligament
and gallbladder are again identified. No biliary dilatation is seen.

Gall Bladder: Multiple stones are identified as previously.

Spleen: No enlargement or mass is seen.

Pancreas: No masses are seen.

Adrenal Glands: No enlargement or mass is seen.

Kidneys: No mass or hydronephrosis is seen.

Retroperitoneum: No adenopathy or hematoma is seen. An inferior vena cava
filter is in place.

Bowel: No dilated large or small bowel is seen.

Appendix: Normal.

Peritoneum: No free fluid or air is seen.

IMPRESSION: Interval increase in pulmonary and hepatic metastasis since the
previous examination.

**End report

I had codes 1629, 1977 but there's far more going on here. Any help on this one would be great. Any ideas?
 

jmcpolin

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well it looks like the lung is also secondary so I would code the 197.0, 197.7 because it is not clear if the cancer started in the liver or the the bile ducts but there does not seem to be anything but stones going on i the gallbladder so I would say since the lung and liver are mets there must be another primary source.
 

troupe327

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Ok, so there was no primary site specified. i have to remember that there won't always be a primary listed on these. I think they should, but sometimes they dont'

Thank you!
 
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