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Conventional arthrogram

  1. #1
    Default Conventional arthrogram
    Medical Coding Books
    Hello List,
    I need some clarification on conventional Arthrograms documentation. Will you look at this report and tell me if this documentation supports one please? Thanks in advance. Denise

    Under fluoroscopic guidance the
    access site was marked on the skin. The skin was prepped and draped
    in the routine sterile fashion. After administering local anesthesia
    a 22 gauge spinal needle was introduced into the shoulder joint using
    an anterior approach. 12 cc of a combination of 5 cc of 1%
    Xylocaine, 5 cc of Omnipaque 300, 10 cc of Bacteriostatic saline and
    0.1 cc of Gadolinium was administered into the joint after confirming
    the location. At the end of the procedure the needle was removed.
    Patient tolerated the procedure without immediate complications.
    Multiple spot views were obtained.
    FINDINGS: The spot views of the left shoulder reveals a good
    distention of the joint with contrast. No evidence for rotator cuff
    tear. Glenohumeral joint and acromioclavicular joint are normal in
    alignment.
    IMPRESSION:
    a. Successful fluoroscopic guided left shoulder
    arthrogram. No evidence for rotator cuff tear.
    b. Patient was shifted to the MR for an MR arthrogram
    which will be interpreted separately.

  2. #2
    Default
    I believe the conventional arthrogram documented in the findins. Hope this helps!

    Thanks,
    Abdul Saleem CPC

  3. #3
    Location
    Birmingham, Alabama
    Posts
    889
    Default
    Quote Originally Posted by dlb_2000 View Post
    Hello List,
    I need some clarification on conventional Arthrograms documentation. Will you look at this report and tell me if this documentation supports one please? Thanks in advance. Denise

    Under fluoroscopic guidance the
    access site was marked on the skin. The skin was prepped and draped
    in the routine sterile fashion. After administering local anesthesia
    a 22 gauge spinal needle was introduced into the shoulder joint using
    an anterior approach. 12 cc of a combination of 5 cc of 1%
    Xylocaine, 5 cc of Omnipaque 300, 10 cc of Bacteriostatic saline and
    0.1 cc of Gadolinium was administered into the joint after confirming
    the location. At the end of the procedure the needle was removed.
    Patient tolerated the procedure without immediate complications.
    Multiple spot views were obtained.
    FINDINGS: The spot views of the left shoulder reveals a good
    distention of the joint with contrast. No evidence for rotator cuff
    tear. Glenohumeral joint and acromioclavicular joint are normal in
    alignment.
    IMPRESSION:
    a. Successful fluoroscopic guided left shoulder
    arthrogram. No evidence for rotator cuff tear.
    b. Patient was shifted to the MR for an MR arthrogram
    which will be interpreted separately.

    documentation of injection, check
    interpretation of images, check

    looks good to me.
    HTH
    Danny L. Peoples
    CIRCC,CPC

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