There are ten radiology medical charts that need to be looked at to see if the codes/modifiers are correct. Some are correct, some are not. I just need #3, #6, #7, and #8 looked at

Radiology

Review the following 10 cases for Thomas Fluroman of Summerfield Radiology. Audit each medical record individually. Use the CMS 1995 and 1997 guidelines and exam tables. Print and use the audit tool of your choice from the Audit Tools folder. Review the charge ticket for the services rendered. You might try using all three tools to find the one that works best for you. Once you have finished auditing the 10 cases, complete the detailed analysis and summary report.

Case #1

Patient Name: John Hammerfield MR 134567901

Date of Exam: 01/19/20xx

EXAM: MRI lower extremity

ADMITTING DIAGNOSIS: Patient States Right Knee Pain-Effusion

CLINICAL HISTORY: RT knee pain.

Comparison: None.

RESULT: Sagittal, axial and coronal images of the right knee were obtained on the 0.23 Tesla open magnet.

The bones are in anatomic alignment. The bone marrow signal intensity is normal. The anterior and posterior cruciate ligaments are intact. There is an oblique tear through the posterior horn of the medial meniscus extending to the inferior surface. There is horizontal tear through the posterior horn of the lateral meniscus extending to the free edge. The medial collateral and lateral collateral ligament complexes are intact. The patellar and quadriceps tendons are intact. There is thinning of the articular cartilage of both the medial and lateral joint compartments, greater laterally. There is mild paraarticular spurring with subchondral cyst formation seen in the lateral tibial plateau. There is no evidence of chondromalacia. There is a small joint effusion. No evidence of a Baker’s cyst.

IMPRESSION:

1. Oblique tear, posterior horn of the medial meniscus extending to the inferior surface.

2. Horizontal tear, posterior horn of the lateral meniscus extending to the free edge.

3. Small joint effusion.

Dict: 01/12/20xx

Time: 1:00 p.m.

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Case #2

Patient: Tom Jones MR 456125

Date of Exam: 01/19/20xx

EXAM: CT Maxillofacial

ADMITTING DIAGNOSIS: Allergic Rhinitis Nasal Congestion

CLINICAL HISTORY: Allergic rhinitis. Nasal conjestion. No comparison.

RESULT: The paranasal sinuses are clear except for a small mucous retention cyst in the base of the right maxillary sinus. This measures about 5 mm. The osteomeatal complexes are patent. There are no air fluid levels. There is mild nasal septal deviation towards the left side. The bones appear intact. There are no soft tissue masses.

IMPRESSION:

1. Acute right maxillary sinusitis.

2. Mild nasal septal deviation towards the left side.

Dict: 01/19/20xx

Time: 3:00 p.m.

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Case #3

Patient: Mary Spinehurst MR: 7845712

Date of Service: 01/10/20xx

EXAM: MRI Study of the Cervical Spine

INDICATION: Neck injury. Pain. Left arm numbness.

RESULT: At the C4-C5 level there is subtle central disc bulge. There is no canal stenosis or foraminal stenosis. At the C-5-C6 level there is slight narrowing of the cervical disc space showing central and bilateral paracentral disc bulge. There is mild canal stenosis and mild bilateral foraminal stenosis. At the C6-C7 level there is a left paracentral disc bulge showing mild left-sided foraminal stenosis. There is no canal stenosis.

IMPRESSION: The remainder of the vertebral bodies and intervertebral disc spaces appear normal. No abnormal bone marrow signal is noted. No abnormal signal is noted involving the cervical cord. The rest of the study is within normal limits.

Dict: 01/11/20xx

Time: 12:30 a.m.

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Case #4

Patient: April Rain MR 1001484

EXAM: MRI Upper Ext. without contrast

ADMITTING DIAGNOSIS: RT Shoulder Pain

CLINICAL HISTORY: Indication: Right shoulder pain and numbness

No comparison study.

RESULT: There are a few small subchondral cysts in the humeral head adjacent to the greater tuberosity. These lie subjacent to the supraspinatus insertion. No other marrow space abnormality is identified. There are mild degenerative changes in the right acromioclavicular joint with small osteocartilaginous spur inferiorly. Undersurface of the acromion is flat. No joint effusion is seen. No abnormal periarticular fluid collections are identified. Glenoid labrum is intact. Long head of the biceps is intact and is normally positioned. Supraspinatus tendon shows no evidence of full thickness tear and there is no evidence of fluid in the subacromial/subdeltoid bursa. I cannot exclude a small partial thickness tear along the distal most aspect of the right supraspinatus tendon in its inferior border. Subscpularis and infraspinatus tendons are intact.

IMPRESSION: Minor degenerative changes of right shoulder. Possible small partial thickness tear along inferior border of right spuraspinatus tendon at tendon insertion, otherwise negative.

Dict: 01/15/20xx

Time: 2:20 p.m.

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Case #5

Patient: Tina Turnaround MR: 4000101

Date of Service: 01/15/20xx

EXAM: MRI Brain W & W/O Contrast

ADMITTING DIAGNOSIS: Lt Facial Weakness/Bell’s Palsy

CLINICAL HISTORY: Comparison. Left facial weakness in a patient w/hx of Bell’s Palsy and MS

RESULT: MRI of the brain was obtained at 1.5 Tesla. Axial T1 weighted pre and post-Gadolinium, T2 weighted FLAIR, and diffusion images were obtained. Sagittal T1 weighted and high resolution coronal and axial pre and post-Gadolinium images of the internal auditory canals were obtained. The old study was available for comparison.

The ventricles and sulci are within normal limits. There is no evidence of mass effect or midline shift. There are no extra-axial fluid collections. There are multiple punctuate areas of abnormal increased T2 weighted signal in the periventricular white matter and in the subcortical white matter of the centrum semiovale. Many of the foci are elongated and oriented toward the ventricles. Since the prior exam, there has been an increase in the number of hyperintense plaques. With contrast enhancement, none of the plaques appear to enhance at this time. The enhancement seen previously has resolved. The pattern and distribution is most characteristic for MS. The pituitary gland and cerebellum are unremarkable. There are multiple punctuate areas of hyperintense signal in the brain stem and brachium pontis. These do not enhance with Gadolinium. There is no edema or mass effect from the lesions. There is a 7 mm. focus of increased signal at the left CP angle. No abnormal signal, enhancement of discrete mass lesion is appreciated within the internal auditory canals. This would correlate with the patient’s symptoms of a left facial palsy.

IMPRESSION: Multiple hyperintense lesions predominately in the periventricular white matter with characteristic pattern for MS. None of the plaques currently enhance. There has been fairly significant increase in the number of lesions since the last exam. Multiple lesions were also seen in the brain stem and the brachium pontis. Specifically, there is an 7 mm. focus in the left. CP angle which is probably the cause of the patient’s left facial palsy. No discrete abnormality was seen in the internal auditory canals.

Dict: 01/15/20xx

Time: 2:20 p.m.

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Case #6

Patient: Doris Williams MR 2111010

Date of Service: 01/20/20xx

EXAM: MRI of the Lumbosacral Spine

ADMITTING DIAGNOSIS: Indication: Patient with low back pain,

Right hip and left leg pain.

RESULT: Parasagittal and axial images were obtained through the lumbosacral spine. There is normal marrow signal seen throughout the vertebral bodies. There is normal disc hydration seen throughout. The conus terminates normally at the level of L1.

L3-4 level: There is a broad-based disc bulge present without focal disc herniation. This, in conjunction with bilateral facet hypertrophy and ligamentum flavum hyupertrophy, is causing some mild canal stenosis. There is also some mild stenosis of the lateral recesses and mild stenosis of right neural exit foramen.

L4-5: There is a broad-based disc bulge present without disc herniation. Bilateral facet and ligamentum flavum hypertrophy is present. This is causing some mild canal stenosis and bilateral mild foraminal narrowing.

L5-S1: Mild broad-based disc bulge is present without disc herniation. There is no canal stenosis. Lateral recesses and neuroforamina are patent bilaterally.

IMPRESSION:

1. Broad-based disc bulge L3-4, L4-5, and L5-S1 levels. No evidence of disc herniation.

2. Bilateral facet and ligamentum flavum hypertrophy at the L3-4 and L4-5 levels. This is causing mild canal stenosis and mild narrowing of the neuroforamina bilaterally at the L4-5 level and on the right at the L3-4 level.

Dict: 1/20/20xx

Time: 9:20 a.m.

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Case #7

Patient: Delaney Brooke MR 89171492

Date of Service: 01/21/20xx

EXAM: CT Abdomen W

ADMITTING DIAGNOSIS: Spleenomegally

CLINICAL HISTORY: Cont Ind: 493.90
Splenomegaly, pancytopenia
Comparison: 1/2/20xx

RESULT: Multi-axial helical images are obtained from the lung bases to the iliac crest following administration of both oral and IV contrast material. Lung bases are clear without focal infiltrate, consolidation, or effusion. There is diffuse fatty infiltration of the liver. There is splenomegaly which is unchanged from the previous exam. The gallbladder, pancreas, adrenal glands, and kidneys are unremarkable.

IMPRESSION: 1. Stable splenomegaly, unchanged from prior study of

1/2/20xx

1. Diffuse fatty infiltration of the liver.

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Case #8

Patient: Donald Peterson MR: 7740798

Date of Service: 01/22/20xx

EXAM: MRI Study of the Cervical Spine

INDICATION: Neck injury. Pain. Left arm numbness.

RESULT: At the C4-C5 level there is subtle central disc bulge. There is no canal stenosis or foraminal stenosis. At the C-5-C6 level there is slight narrowing of the cervical disc space showing central and bilateral paracentral disc bulge. There is mild canal stenosis and mild bilateral foraminal stenosis. At the C6-C7 level there is a left paracentral disc bulge showing mild left-sided foraminal stenosis. There is no canal stenosis.

IMPRESSION: The remainder of the vertebral bodies and intervertebral disc spaces appear normal. No abnormal bone marrow signal is noted. No abnormal signal is noted involving the cervical cord. The rest of the study is within normal limits.

Dict: 1/20/20xx

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Case #9

Date of Service: 1/30/20xx

EXAM: CT Abdomen W

ADMITTING DIAGNOSIS: Gallbladder Problem

CLINICAL HISTORY: Right upper quadrant abdominal pain. History of colon cancer. Colostomy. Comparison: None.

RESULT: The study was performed with oral and intravenous contrast material. The lung bases appear normal. The liver, spleen, both kidneys and adrenal glands appear normal. There is faint calcific density in the dependent portion of the gallbladder, suspicious for a possible gallstone. Recommend ultrasound correlation. Visualized portions of the pancreas appears unremarkable. There is no retroperitoneal lymphadenopathy. Opacified bowel loops are unremarkable. Note is made of left lower quadrant colostomy. No abnormality is noted within the pelvis.

IMPRESSION: Small calcific density in the dependent portion of the gallbladder, suspicious for gallstone. Recommend ultrasound correlation.

Dict: 1/31/20xx

Time: 5:30 p.m.

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Case #10

Sherry Marksman MR 1009574

Date of Procedure: 01/15/20xx

EXAM: BR Stereo Guidance

ADMITTING DIAGNOSIS: Bilateral Calcifications

CLINICAL HISTORY: Asymptomatic – Bilateral in determinate
Calcifications.

RESULT: After informed consent was obtained, the patient was placed in the stereotactic table in the prone position. The calcifications in the left breast were evaluated. Using a superior approach multiple core samples were obtained. The patient tolerated the procedure well without complications. Specimen radiograph confirmed calcifications in the specimen. A small tissue marker was deployed in the biopsy bed. The calcifications were completely removed and the tissue marker was in the biopsy bed with a small 2cm hematoma in the biopsy bed on the post procedure mammogram.

The right breast was then placed in the stereotactic table and using an inferior approach the calcifications were localized stereotactically. Multiple core samples were obtained. Specimen radiograph calcifications within the specimen. The patient tolerated the procedure well. A small tissue marker was deployed in the biopsy bed. Post procedure mammograms confirm the clip in the biopsy bed without significant complications or hematoma.

IMPRESSION: Successful bilateral stereotactic biopsies. Tissue markers were deployed in the biopsy beds with tissue markers in the biopsy beds confirmed on the post procedure mammograms. Specimen radiographs were positive for the right and left breast.

Dict: 1/25/20xx

Time: 10:14 a.m..

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Medical Record Auditor, 4e. Copyright American Medical Association.