Question

Assign CPT and ICD-10-CM codes to this Radiology Service.

LOCATION: Outpatient, Hospital
PATIENT: Joe Turner
PHYSICIAN: Jeff King, M.D.
RADIOLOGIST: Morton Monson, M.D.
EXAMINATION OF: CT of paranasal sinuses
CLINICAL SYMPTOMS: Chronic sinusitis

COMPUTED TOMOGRAPHIC EXAMINATION OF THE PARANASAL SINUSES was performed in the coronal plane utilizing thin, overlapping sections computed for high-resolution bone algorithm. Ultra-thin (1 mm) sections were performed through the drainage pathways of the maxillary sinuses. Frontal sinuses are generous in size. They are well aerated but there is mucosal thickening inferiorly near the frontal nasal duct of each side. Many ethmoid sinuses are clear and well aerated without significant mucosal abnormality. However, some ethmoid sinuses show mucosal thickening and several ethmoid sinuses show abnormal soft tissue within.

In images 20 and 21, there is a 1 cm diameter soft tissue mass on the left. I believe this is within the ethmoid complex, rather than the left sphenoid sinus. I believe the sphenoid sinuses are clear and well aerated. Bilaterally, the maxillary sinuses are well aerated, but they both show considerable mucosal thickening and/or granulation tissue from previous inflammatory episodes. I cannot visualize a patent drainage pathway of either of the maxillary sinuses. I believe these are occluded. Nasal septum shows mild deviation to the right. Superior half of the nasal cavity is comprised of ethmoid air cells entering the middle turbinate. Some of the mucosal nodulations related to the ethmoid and maxillary sinuses have rounded margins and might represent polyps.

Answer 1

ANSWERS

* ICD-10-CM Code

             * J32.9 - Chronic sinusitis,unspecified.

* CPT Code

             * 70486 - Computed tomography,maxillofacial area; without contrast material.

                           ( this cpt code represent CT of paranasal sinuses)