Answer Happy

Using the coding techniques you have learned, carefully read
through the case study and determine the most accurate procedure
code(s) and modifier(s), if appropriate.
PRADER, BRACKER, & ASSOCIATES
A Complete Health Care Facility
159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789
PATIENT: HOLDER, ANDREW
ACCOUNT/EHR #: HOLDAN001
DATE: 12/10/22
Procedure Performed: CT brain w/o
contrast
Radiologist: Michael B. Hawkins, MD
Clinical Information: Evaluation for VP
shunt, postsurgical
Attending Physician: Renee O. Bracker,
MD
TECHNICAL INFORMATION: Contiguous
3-mm-thick axial images were obtained through the skull base and
posterior fossa structures followed by 7-mm-thick axial images
through the remainder of the brain. The examination was performed
without the use of intravenous contrast material.
The scan was performed at an independent imaging center and sent
to me via secured PACS system, so I could interpret.
INTERPRETATION: Evaluation of the
posterior fossa demonstrates bilateral vertebral artery
calcification. No abnormal intra- or extra-axial collections are
noted. There is no evidence of midline shift.
Analysis of the region of the sella turcica demonstrates
calcification, likely atherosclerotic involving the cavernous
carotid arteries bilaterally seen on series 2 image 7.
Supratentorially, the lateral ventricles are prominent in size.
A ventriculostomy catheter is seen coursing from the region of the
postcentral sulcus with its distal tip terminating within the
frontal horn of the right lateral ventricle abutting the septum
pellucidum. Hypodensity is seen within the periventricular white
matter particularly abutting the frontal horns of the lateral
ventricles bilaterally. There is a mild degree of cerebral volume
loss. No abnormal intra- or extra-axial collections are noted.
Evaluation of the visualized skull and paranasal sinuses
demonstrates a right parietal burr hole defect for placement of the
patient’s ventriculostomy catheter. A subcutaneous ventriculostomy
valve is seen on series 3 image 26.
RECOMMENDATIONS: There is mild prominence
of the lateral ventricles bilaterally without evidence of dilation
of the cerebral aqueduct or fourth ventricle.
Be sure to list the codes, one code per box, in the correct
sequence, from top to bottom, and in the proper row.
Capitalization, punctuation, and spacing can impact whether or not
your answer is correct. Follow coding best practices. Please list
modifiers with the code they relate to as necessary. Include a
hyphen in between the code and the modifier. Example
Procedure: 43846-74 or for Anesthesia: 00797-P2.
Determine the most accurate CPT code(s) and necessary
modifier(s) for the CT scan.
The number of spaces provided does not indicate the number of
codes required to accurately report this encounter.
CPT code(s) and any applicable modifier(s) Anesthesia code(s) and any applicable modifier(s) HCPCS Level II code(s) and any applicable modifier(s)