COMPLETE QUESTIONS
WK3 QUESTION2 HP-216
Instructions: Assign the most appropriate CPT procedure code(s) including any needed modifiers.
Question
REASON FOR EXAM: Right upper quadrant abdominal pain.
Multiple B-mode scans of right upper quadrant reveal good visualization of the gallbladder. There are several small, dense echoes in the dependent portion of the gallbladder with acoustic shadowing defects distally. The findings are suggestive of cholelithiasis. The rest of the abdominal cavity organs appear normal in size and appearance; this includes the liver, pancreas, spleen, and kidneys.
Assign CPT code(s): FILL IN BLANK
2) X-RAY OF CERVICAL SPINE, ANTEROPOSTERIOR AND ODONTOID VIEWS; X-RAY OF LUMBOSACRAL SPINE, ANTEROPOSTERIOR, ODONTOID, AND OBLIQUE VIEWS
REASON FOR EXAM: Rule out lumbar fracture. Lumbar back pain.
No fractures or dislocations are evident. A total of four views are obtained of the lumbar spine, which show the lumbar vertebrae to be normal. The alignment is anatomical. The disc spaces and intervertebral foramina are well maintained.
IMPRESSION: Normal lumbar and cervical spine
Assign CPT code(s): FILL IN BLANK, FILL IN BLANK
REASON FOR EXAM: Rib pain.
Two views reveal no evidence of any rib fracture. The underlying lung is normal. The heart is moderately enlarged, and there is evidence of coronary artery surgery. Incidentally demonstrated is a 4-cm laminated gallstone in the right upper abdomen.
Assign CPT code(s): FILL IN BLANK
4) X-RAY, LEFT WRIST; X-RAY, LEFT SHOULDER
REASON FOR EXAM: Pain, left shoulder. Check left wrist closed (lower end) fracture healing and left humerus (upper end) closed fracture healing.
LEFT WRIST: Anteroposterior and lateral views taken through plaster show that the fracture of the distal radius remains in excellent alignment.
LEFT SHOULDER: Multiple views of the left shoulder show that the fracture of the upper end of left humerus is in excellent alignment.
Assign CPT code(s): FILL IN BLANK, FILL IN BLANK
REASON FOR EXAM: Shortness of breath.
The lungs are clear. No pleural effusion. The heart is normal. Pneumothoracic scoliosis is noted. In comparison with the previous examination of 10/10/YY, there is no essential interval change.
The patient has known pneumothoracic scoliosis and has long experienced shortness of breath. The patient’s primary care provider monitors increased shortness of breath via chest X-ray to determine if it has become lung-related. For this encounter, the shortness of breath remains related to pneumothoracic scoliosis. Reason for chest x-ray is shortness of breath.
SUMMARY: Negative.
Assign CPT code(s): FILL IN BLANK
REASON FOR EXAM: Pain in jaw.
Three views of the left mandible show no definite evidence of a fracture. However, the mandible is not optimally visualized in this study.
Assign CPT code(s):FILL IN THE BLANK
7) LIVER AND SPLEEN SCAN, WITH VASCULAR FLOW
REASON FOR EXAM: Abnormal liver function studies per laboratory report.
The liver and spleen were imaged under vascular flow. The liver is slightly enlarged, but good flow was seen. The spleen appears normal.
Assign CPT code(s)FILL IN BLANK
REASON FOR EXAM: Lumbar back pain.
Axial images were obtained throughout L3, L4, and L5 levels using magnification technique. There is disc material protruding from the posterior aspect of L4 level on the right sde. This is causing almost complete obliteration of the nerve canal and measures roughly 6 mm in size. The remainder of this disc as well as L3 and L5 disc levels appear normal.
CONCLUSION: Findings consistent with a herniated disc at L4 level on the right side.
DIAGNOSIS: Herniated disc, L4, right.
Assign CPT code(s) FILL IN BLANK
REASON FOR EXAM: Elbow pain, left.
Anteroposterior and lateral views are normal.
Assign CPT code(s FILL IN BLANK
REASON FOR EXAM: Pain, left shoulder. Rule out fracture.
Anteroposterior and lateral views reveal a comminuted, slightly angulated, closed fracture of the neck of the humerus. I do not see any other acute abnormality. There is an old healed fracture of the left clavicle.
DIAGNOSIS: Comminuted nondisplaced closed fracture, neck of left humerus. (Initial encounter for closed fracture.)
