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how would you code this?

  1. #1
    Unhappy how would you code this?
    Exam Training Packages
    I work for a radiology group and one of our provides dictates a body scan this way


    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.
    Words: 126 Chars: 842

    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

  2. #2
    Default Radiology Question
    Since it appears he only took images of the spine I think I would code the 78300, limited area.

  3. #3
    I agree, limited area since only the spine is involved.

  4. #4
    Thanks, That is what I thought. I will need to get him to change the title.

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