Part B Insider (Multispecialty) Coding Alert

When doctors jumble exam reports, auditors may target your claim

You know your physician's documentation isn't always perfect, and we-ve got a real-life example right here. Read through the report and determine how you would code. Then see the inset on the next page for what our coding expert has to say.
 
CLINICAL HISTORY: Follow-up sigmoid colon cancer with pulmonary metastasis.

CT SCAN OF THE CHEST, ABDOMEN, AND PELVIS WITH CONTRAST

TECHNIQUE: 5-mm sections through the chest, abdomen, and pelvis were obtained with 100 cc of Isovue 300 (non-ionic) contrast agent intravenously without incident, and oral contrast and images viewed in soft tissue, lung, and liver windows. Comparison is made with a previous examination performed on 06/02/06.

Indication for the use of non-ionic contrast: No specific indication given.

FINDINGS: Again, there are several pulmonary nodules bilaterally, consistent with metastases. The majority of the previously seen nodules have either decreased in size or resolved. There are new pulmonary nodules. The previously seen scattered ground glass opacities, most prominent at the left lung base, have resolved. The previously seen prominent subcarinal and left hilar lymph nodes have decreased in size as well. Subcarinal lymph node measures 7 mm x 19 mm on image #28. Previously, it measured 11 mm x 26 mm.

There is no bulky axillary, mediastinal or hilar lymphadenopathy. The heart is stable. Left subclavian Infuse-A-Port catheter has been placed in the interim.

Previously noted hypodensity within the dome of the liver is less conspicuous and actually appears to be volume averaging within the perihepatic fat. The hypodensity within the medial aspect of the left hepatic lobe is adjacent to the falciform ligament in a good place for fatty infiltration. Otherwise, the liver is normal. Gallbladder, spleen, pancreas, adrenal glands and kidneys are stable. A simple cyst is seen within the parapelvic region of the right kidney.

There is moderate symmetric concentric thickening involving the distal sigmoid colon which is less nodular when compared to previous examination. Again, there is mild increased attenuation of the perisigmoid and rectal fat, which may be related to radiation therapy changes. There is mild sigmoid and descending colon diverticulosis. Otherwise, the bowel is unremarkable. No bulky lymphadenopathy or ascites. Mildly prominent celiac axis lymph node is unchanged. Best seen on image #86, just posteromedial to the spleen, there is a 6- x 15-mm soft tissue density nodule along the posterior peritoneal surface that is nonspecific but unchanged from prior examination.

IMPRESSION:

1. Persistent but improved bilateral pulmonary metastases.
2. Mildly prominent subcarinal and left hilar lymph nodes have decreased in size. Mildly prominent celiac axis lymph node is stable.
3. Hepatic hypodensities likely represent a combination of volume averaging and focal fatty infiltration. There is no new hepatic lesion to suggest metastasis.
4. Persistent left nodular sigmoid colon wall thickening. Adjacent mesenteric and induration may be related to radiation therapy changes.
5. Stable small nodule along the left posterior peritoneal surface is stable.