Eunice Posted Tue 03rd of July, 2012 16:35:44 PM
Can someone please explain to be how to charge this report?
WHOLE BODY BONE SCAN AND THREE-PHASE SCAN OF THE FEET:
CLINICAL DATA: Remote breast cancer. Pain in left foot for two weeks. Left foot surgery on the great toe in 2007. Possible stress fracture.
FINDINGS: Three-phase bone scan of the feet is undertaken in the usual fashion with intravenous administration of 26.1 mCi of technetium labeled MDP.
There is increased activity into the left leg and the left foot, on the arterial images and also notable on the venous/equilibrium images. The increased activity is confirmed on the composite images. In the left foot, the increased activity is particularl
y notable around the first MP joint, and the second metatarsal.
On immediate and static delayed images, there is notable pattern of increased activity at the left first MP joint, consistent with degenerative change and perhaps residual deformity from prior surgical intervention.
In addition, there is increased activity in the distal diaphyseal region of the second metatarsal. This activity could be secondary to a stress fracture in the second metatarsal. There is minimal increased activity in the lateral tarsal metatarsal region
of the left foot.
There is minimal activity in the right foot at the first MP joint, suggesting minimal degenerative change. There is also minimal activity in the lateral aspect of the tarsal metatarsal region of the right foot, also perhaps reflecting minimal degenerative
Whole body bone scan images demonstrate a generally normal pattern of radionuclide accumulation throughout the skeletal system, but for slight increased activity at the first metacarpal-greater multangular joint of both hands, consistent with focal degene
rative arthritis. Minimal activity is noted in the left patellofemoral compartment as well. Elsewhere, the skeletal system is unremarkable. At this time, there is no indication of bony metastatic disease.
IMPRESSION: INCREASED ACTIVITY IN THE LEFT SECOND METATARSAL, CONSISTENT WITH A STRESS FRACTURE. INCREASED ACTIVITY IN THE FIRST LEFT MP JOINT, CONSISTENT WITH ARTHRITIC CHANGE AND/OR RESIDUAL DEFORMITY FROM OPERATIVE INTERVENTION IN THE PAST.
MINIMAL DEGENERATIVE CHANGES ELSEWHERE.
SuperCoder Answered Thu 05th of July, 2012 07:13:50 AM
The appropriate CPT code for the Given Scenario would be: 78315
A three phase study refers to a bone scan that starts immediately with a blood flow study. The blood flow study is done during and immediately after injection of a bone seeking radiopharmaceutical agent and consists of sequential short interval images of one area followed by a static image of the same region right after the bolus of blood has diffused. A bone scan is performed three to four hours later, which consists of a limited, multiple or a whole body bone scan.
Simply CPT code 78315(three phase scan) include 78306 (whole body scan), hence would not be reported separately.