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Code?

  1. #1
    Default Code?
    Medical Coding Books
    What is the code for this study? I coded a ton of nuclear stress test reports but this report is a little different. Its a thallium viability study is what the doctor wrote down.

    Type of exam: Thallium; Rest Only

    Indication: Severe coronary disease and left ventricular dysfunction.

    Nuclear protocol: Prior to the initial scan, 4.3 millicuries of Thallium were injected IV. Immediate scanning took place, as well as scanning at 3 hours and 24 hours.

    Findings: The left ventricle appears dilated. This study was not gated for left ventricular systolic function. The resting images show a severe perfusion defect in the distal anterior wall and distal inferior wall. There is completely absent perfusion in the apex. On both the 3 hour and 24 hour redestribution images, there is no improvement in uptake in the distal anterior wall or apex. The distal inferior wall appears to have slight increased uptake on the redistribution scans, but for the most part, the entire inferior wall has markedly decreased uptake on both the resting scan and the delayed uptake scans.

    I was at first thinking 78452-26 but I don't see the word SPECT at all in this report. Would this be coded as a multiple planar study then? (Rest images and redistrubution images)

    Thanks.

  2. Default
    Quote Originally Posted by Jess1125 View Post
    What is the code for this study? I coded a ton of nuclear stress test reports but this report is a little different. Its a thallium viability study is what the doctor wrote down.

    Type of exam: Thallium; Rest Only

    Indication: Severe coronary disease and left ventricular dysfunction.

    Nuclear protocol: Prior to the initial scan, 4.3 millicuries of Thallium were injected IV. Immediate scanning took place, as well as scanning at 3 hours and 24 hours.

    Findings: The left ventricle appears dilated. This study was not gated for left ventricular systolic function. The resting images show a severe perfusion defect in the distal anterior wall and distal inferior wall. There is completely absent perfusion in the apex. On both the 3 hour and 24 hour redestribution images, there is no improvement in uptake in the distal anterior wall or apex. The distal inferior wall appears to have slight increased uptake on the redistribution scans, but for the most part, the entire inferior wall has markedly decreased uptake on both the resting scan and the delayed uptake scans.

    I was at first thinking 78452-26 but I don't see the word SPECT at all in this report. Would this be coded as a multiple planar study then? (Rest images and redistrubution images)

    Thanks.
    I would code if multiple rest and stress ( 78452) if single (78451)

  3. Default
    I agree, because it states Thallium rest, I would take it as Thallium Lexiscan in our office and code 78452 but that would be in my office so may be different for you. Good luck!

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