Shirleybala
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Hi,
How to coded this myelogram,will these three codes come(62284, 72240, 72126) plz confirm
Technique: After 10 cc of Omnipaque 240 was administered into the
thecal sac, under fluoroscopic visualization, a CT cervical
myelogram was performed, with multiple axial CT images through the
cervical spine obtained. Sagittal and coronal reformats were then
performed. The images were reviewed in soft tissue and bone
windows.
Comparison is made with prior MRI done on 9/12/2008.
Findings:
There is straightening of the cervical spine seen. The cervical
alignment is normal. The vertebral body heights are preserved.
There is intervertebral disk space narrowing seen at the C5/6 and
C6/7 levels.
No intradural or paraspinal abnormality is seen. The cerebellar
tonsils are normal in position.
At the C2/3 and C3/4 levels, there are again noted small central
disk herniations, indenting the thecal sac without cord
compression, as observed on the prior MRI examination. The neural foramina are patent at these levels.
At the C4/5 level, there is a large left paracentral disk
herniation, resulting in moderate flattening of the ventral
spinal cord margin, as observed on the prior MRI examination. No
neural foraminal stenosis is observed.
At the C5/6 level, there is a left paracentral disk herniation,
resulting in mild-moderate flattening of the the ventral spinal
cord margin, as observed on the prior MRI examination. No neural
foraminal stenosis is observed.
At the C6/7 level, there is a left paracentral disk herniation,
resulting in mild-moderate flattening of the ventral spinal cord,
as observed on the prior MRI examination. Moderate left foraminal
stenosis is observed.
At the C7-T1 level, there is a minimal annular bulge without
spinal stenosis or cord compression.
There is minimal ossification the posterior longitudinal ligament
behind the C6 vertebral body.
IMPRESSION:
Multilevel disc herniations are observed at C2-3 through C6-7 with
associated anterior cord flattening at C4-5, C5-6, C6-7. Largest
disk herniation as well as the greatest degree of the anterior
cord flattening is at the C4-5 level. Minimal annular bulge is
also identified at C7-T1 .
How to coded this myelogram,will these three codes come(62284, 72240, 72126) plz confirm
Technique: After 10 cc of Omnipaque 240 was administered into the
thecal sac, under fluoroscopic visualization, a CT cervical
myelogram was performed, with multiple axial CT images through the
cervical spine obtained. Sagittal and coronal reformats were then
performed. The images were reviewed in soft tissue and bone
windows.
Comparison is made with prior MRI done on 9/12/2008.
Findings:
There is straightening of the cervical spine seen. The cervical
alignment is normal. The vertebral body heights are preserved.
There is intervertebral disk space narrowing seen at the C5/6 and
C6/7 levels.
No intradural or paraspinal abnormality is seen. The cerebellar
tonsils are normal in position.
At the C2/3 and C3/4 levels, there are again noted small central
disk herniations, indenting the thecal sac without cord
compression, as observed on the prior MRI examination. The neural foramina are patent at these levels.
At the C4/5 level, there is a large left paracentral disk
herniation, resulting in moderate flattening of the ventral
spinal cord margin, as observed on the prior MRI examination. No
neural foraminal stenosis is observed.
At the C5/6 level, there is a left paracentral disk herniation,
resulting in mild-moderate flattening of the the ventral spinal
cord margin, as observed on the prior MRI examination. No neural
foraminal stenosis is observed.
At the C6/7 level, there is a left paracentral disk herniation,
resulting in mild-moderate flattening of the ventral spinal cord,
as observed on the prior MRI examination. Moderate left foraminal
stenosis is observed.
At the C7-T1 level, there is a minimal annular bulge without
spinal stenosis or cord compression.
There is minimal ossification the posterior longitudinal ligament
behind the C6 vertebral body.
IMPRESSION:
Multilevel disc herniations are observed at C2-3 through C6-7 with
associated anterior cord flattening at C4-5, C5-6, C6-7. Largest
disk herniation as well as the greatest degree of the anterior
cord flattening is at the C4-5 level. Minimal annular bulge is
also identified at C7-T1 .