Wiki Radiology Coding Help 78195 with 78803

[neelaprakash]

Need coding Guidance -​

Will this be coded as 78195 or 78195+78803?

Thank you in advance.

CLINICAL INFORMATION:​

Male 68 years old Reason: mapping to sentinel node of left nose
sidewall/lower eyelid History: melanoma of the face

RADIOPHARMACEUTICAL:​

The left nasal area was prepared in a sterile manner. A total of 0.5
mCi Tc-99m filtered sulfur colloid was injected in four perilesional injections. SPECT
imaging of the thorax was obtained. (The low-dose noncontrast CT was not of diagnostic
quality and used only for attenuation correction and localization of the SPECT images).

COMPARISON:​

None.

FINDINGS:​

Planar/SPECT: A focus of increased activity is noted in left nasal area corresponding to
the area of injection. There is an avid left level 1B cervical lymph node at the angle of
the mandible, representing the sentinel node. This region was marked with an indelible
marker. An additional early draining lymph node is also seen at left level 2B.

CT: There is opacification of bilateral maxillary sinuses and scattered bilateral anterior
ethmoidal air cells, suggestive of sinusitis in the appropriate setting. An intramuscular
lipoma of the right infraspinatus muscle is noted. Minimal atherosclerosis of the aortic
arch.

IMPRESSION:​

Sentinel node identified in the left neck at level 1B.