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RADIOLOGY REPORT LOCATION: Outpatient, Hospital PATIENT: Eric Tayes ORDERING PHYSICIAN: Frank Gaul, MD ATTENDING/ADMIT PHYSICIAN: Frank Gaul, MD RADIOLOGIST: Morton Monson, MD EXAMINATION:
Ultrasound of both lower extremities; abdomen ultrasound. CLINICAL SYMPTOMS: Lower extremity swelling, difficulty breathing. FINDINGS: Ultrasound examination of the deep venous system of both lower extremities is negative. No evidence of deep venous thrombosis in either lower extremity. The posterior tibial, greater saphenous, and popliteal through femoral veins are patent and negative for thrombus bilaterally. Normal phasicity. Abdomen Ultrasound: Diffusely coarsened echotexture of the liver with some nodularity consistent with fatty infiltration. Cirrhotic configuration of the liver. Small calcified granuloma in the spleen. The spleen is otherwise negative. There is ascites in all four quadrants. No bile duct dilatation. No gallbladder wall thickening or cholelithiasis. Small amount of fluid adjacent to the gallbladder is likely related to the ascites. The pancreas is obscured by bowel gas. The abdominal aorta is of normal caliber. The right kidney measures approximately 9 cm in length and shows no evidence of hydronephrosis, calculi, or mass. The left kidney measures approximately 9.9 cm in length and shows no evidence of hydronephrosis, calculi, or mass. What modifier should be added to the CPT-4 code in order to submit the insurance claim?
Medicare Part B requires one single line of bilateral procedure code with Modifier 50. They normally process the claim with 150% reimbursement. [ But again, you have to check on this in your state and in your region. Some commercial insurance would prefer Two Lines of the same code, once with 50, second without 50. Then second modifier on the 1st line is RT or LT, modifier RT or LT on second
line, with 1 unit of service each code. Must be reimbursed at 150% Some commercial insurance would prefer two lines of the same code with modifier LT or RT on each line with 1 unit of service each code. Must be reimbursed at 150% ]
Expert answered|brenda143|Points 52|
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Asked 7/7/2012 8:31:39 PM
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LOCATION: Hospital Emergency Department PATIENT: Fran Green PHYSICIAN: Paul Sutton, MD CHIEF COMPLAINT: Level 3 trauma SUBJECTIVE: A 44-year-old female was treating a sick calf when a cow attacked and stomped her. She presents to the emergency room via ambulance complaining of an open ankle dislocation. She is also complaining of some abrasions on her chin and under her left leg. She specifically denies loss of consciousness or headache. No neck, back, chest, abdomen, or pelvic pain. She is ...
NOTE: You are coding for the emergency room physician’s services only, not the hospital facility charges.) CPT-4:___________________ Weegy: Please clarify your question. User: LOCATION: Hospital Emergency Department PATIENT: Fran Green PHYSICIAN: Paul Sutton, MD CHIEF COMPLAINT: Level 3 trauma SUBJECTIVE: A 44-year-old female was treating a sick calf when a cow attacked and stomped her. She presents to the emergency room via ambulance complaining of an open ankle dislocation. She is also complaining of some abrasions on her chin and under her left leg. She specifically denies loss of consciousness or headache. No neck, back, chest, abdomen, or pelvic pain. She is quite stoic. PAST MEDICAL HISTORY: Remarkable for some hypertension, depression, and migraine. MEDICATIONS: 1. Premarin 2. Question Xanax ALLERGIES: None FAMILY HISTORY: Deemed noncontributory SOCIAL HISTORY: She is married; I believe is a nonsmoker, and is a laborer. REVIEW OF SYSTEMS: As above. She says her foot is cold. PHYSICAL EXAMINATION: Preliminary survey is benign. Secondary survey: Alert and oriented X 3. Immobilized in a C-collar and long spine board. Head is normocephallic. There is no hemotympanum. Pupils are equal. There is an abrasion under her chin. Trachea is midline. She does have a C-collar in place. Air entry is equal. Lungs are clear. Chest wall is nontender. Abdomen is soft. Pelvis is stable. Long bones are remarkable for an obvious open dislocation of the right ankle. The toes are all dusky, she has a strong posterior tibial pulse, and the nurse thinks she felt a faint dorsalis pedis. She has an abrasion under her left leg. HOSPITAL COURSE: We did give her a tetanus shot and 1 g of Ancef. I immediately gave her some parenteral Fentanyl and Versed, and we were able to reduce the dislocation without difficulty. Postreduction film looks surprisingly good. There is perhaps a subtle fracture noted only on the lateral projection. C-Spine shows some degenerative change, is of ... (More)
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