RadVCCoder
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Can I get feedback on how you would code this report. It is on a 91 yr old Male. I am leaning towards CPT code 49329 but would like feedback on how it goes.
EXAM:
CT GUIDED PROCEDURE without SEDATION
INDICATION:
New intraperitoneal metastatic disease with omental caking and peritoneal
implants and ascites from uncertain source. Suggest correlation with
cytology/fluid sampling or tissue sampling from the omentum.,Metastatic
malignant neoplasm, unspecified site (HCC)
TECHNIQUE:
While obtaining CT images, dose reduction techniques were utilized including:
Automated exposure control, adjustment of mA and/or kV according to patient
size, and/or use of iterative reconstruction technique.
RADIATION DOSE:
569 DLP (mGy cm)
PROCEDURE:
Consent: The risks, benefits, and alternatives of the procedure were discussed
with the patient. Verbal and written consent was obtained.
Site Preparation: The patient was prepped and draped in usual sterile fashion.
Lidocaine 1% was used for local anesthesia.
Device: 18 gauge Temno
Placement site: Anterior abdominal wall
Sample: 2 cores placed in formalin
Complications: None.
Patient disposition: Discharged from the department in stable condition.
Blood loss: Less than 5 mL
IMPRESSION:
CT guided omental biopsy.
EXAM:
CT GUIDED PROCEDURE without SEDATION
INDICATION:
New intraperitoneal metastatic disease with omental caking and peritoneal
implants and ascites from uncertain source. Suggest correlation with
cytology/fluid sampling or tissue sampling from the omentum.,Metastatic
malignant neoplasm, unspecified site (HCC)
TECHNIQUE:
While obtaining CT images, dose reduction techniques were utilized including:
Automated exposure control, adjustment of mA and/or kV according to patient
size, and/or use of iterative reconstruction technique.
RADIATION DOSE:
569 DLP (mGy cm)
PROCEDURE:
Consent: The risks, benefits, and alternatives of the procedure were discussed
with the patient. Verbal and written consent was obtained.
Site Preparation: The patient was prepped and draped in usual sterile fashion.
Lidocaine 1% was used for local anesthesia.
Device: 18 gauge Temno
Placement site: Anterior abdominal wall
Sample: 2 cores placed in formalin
Complications: None.
Patient disposition: Discharged from the department in stable condition.
Blood loss: Less than 5 mL
IMPRESSION:
CT guided omental biopsy.
