how would you code this?
I work for a radiology group and one of our provides dictates a body scan this way
WHOLE BODY BONE SCAN WITH SPECT IMAGES OF THE SPINE:
HISTORY: Back pain.
TECHNIQUE: Following intravenous administration of * mCi technetium 99-M MDP, detail views were obtained of the lumbar spine and all projections. Computed emission tomograms were also obtained the lumbar spine in the coronal, sagittal, and axial planes.
Conventional images: Intensely increased uptake in the superior endplate of L3 and inferior endplates of L1 and L2 on the right. Evidence of posterior lateral fusion mass at L4-S1 with no focally increased uptake. Few degrees of leftward thoracolumbar curvature.
SPECT images: The SPECT images showed increased uptake anteriorly at L2-L4 and intensely increased uptake in the posterior elements at L3-4. Moderately increased uptake at the level of the left L5 pars and adjacent facet joints.
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1. Mild S-shaped scoliotic curvature with evidence of previous L4-S1 fusion.
2. Increased uptake in the anterior elements of L1-L3.
My question is is this a whole body scan or an limited body scan? we are having a discussion on which code to use 78300 or 78306?
Thanks for your help
EVELYN KIM , MBA, CPC, CRC
Revenue Cycle Supervisor