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Download the Imaging Report in Blackboard, review the Imaging Report, and then assign the appropriate CPT code(s) and HCPCS supply code (s) by adding these codes to the coding template.
In Module 4 lecture, you will learn about Local and National Coverage Determinations. Using Medicare’s website https://www.cms.gov/medicare-coverage-database/search.aspx, you will determine whether or not the Imaging CPT procedure has an active Local Coverage Determination (LCD) or Local Coverage Article (LCA) based on the CPT Imaging code assignment from the Imaging Report. This will be identified on the coding template.
On the same coding template, eflect on your method for finding the codes for this patient. Describe in detail the steps you have taken to ensure you have this coded properly.

 

Imaging Report

Date:  2/28/xx

Patient Name:  Jane Smith 

Patient’s DOB:  1/3/65

Service Description: Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; Skull to Mid thigh

PET CT Result

Indication: 
Malignant neoplasm of unspecified site of unspecified female breast, breast staging 

Technique: 
PET CT was performed from the base of the skull to the upper thighs following intravenous injection of Fluorodeoxyglucose.  Non IV enhanced CT is used for attenuation correction and anatomical localization. 

Comparison: 
None. 

Findings: 
Mediastinal blood pool SUVavg is 2.0. 

Head and Neck: Physiologic FDG uptake 

 

Thorax: There is mildly increased uptake within the lateral left breast consistent with prior biopsy of known malignancy (SUV max 1.7).  There is no evidence of axillary or internal mammary hypermetabolic lymphadenopathy. 

Abdomen and Pelvis: Physiologic FDG uptake 

Osseous Structures: Physiologic FDG uptake 

Impression: 
Mildly increased uptake within the lateral left breast in the area of prior biopsy of known malignancy. 

No evidence of hypermetabolic axillary or internal mammary lymph nodes. 

No metabolic evidence of distant metastatic disease. 

 

Electronically Signed By: 

 

Peter Clark, MD 15:30 2/28/xx

SCIENCE
HEALTH SCIENCE
NURSING
MCCG 146

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