AMA Clinical Examples in Radiology - 2018 Issue 2 (Spring)
Bone Marrow Biopsy and Aspiration
CLINICAL EXAMPLE 2 Bone Marrow Biopsy and Aspiration CLINICAL DATA A 57-year-old male patient presents with pancytopenia and concern for non-Hodgkin's lymphoma. PROCEDURE 99152 99153 X 3 Moderate sedation was used during the procedure. Informed consent was obtained, and a time-out was performed. Conscious sedation was administered using 1 mg of midazolam and 100 μg of fentanyl intravenously. The physician and nursing staff monitored the patient's level of consciousness and physiologic status throughout the procedure. Total intraservice moderate sedation time was 60 minutes. 77012 38222 The patient was placed in the prone position on the computed tomography...
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Article Overview
This article explains a radiology coding example centered on a diagnostic bone marrow biopsy and aspiration encounter. It is useful for coders working with CPT, ICD-10-CM, and radiology documentation because it discusses how the case is presented, what code families are involved, and how associated guidance and diagnosis reporting are addressed in the accompanying discussion.
Why This Topic Matters
Bone marrow procedures may involve multiple services in one encounter, and the article helps readers understand the scope of related documentation and coding references in a single case example.
Article Sections
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Clinical Example 2
A sample patient encounter is presented with procedure documentation and imaging context. The section frames the clinical scenario for the coding discussion that follows.
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Findings
This section summarizes the imaging observations associated with the encounter. It provides the procedural context but does not stand alone as coding guidance.
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Impression
A brief summary of the overall outcome of the procedure is provided here. It supports the example case and its documentation context.
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How to Code
This section identifies the code sets and reporting topics tied to the example. It also introduces broader discussion of related procedure and diagnosis coding references.
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Discussion
The discussion reviews related code updates, coding context, and accompanying reporting notes from the referenced coding resources. It also mentions broader considerations relevant to the procedure family and associated documentation.
What You Will Learn
- How the article organizes a bone marrow procedure example for coding review
- Which coding domains are involved in the case discussion
- What kinds of related documentation topics are addressed in the explanatory text
- How the article situates the example within broader CPT and ICD-10-CM guidance
Who Should Read This
- Medical coders
- Coding educators
- Radiology coding professionals
- Clinical documentation staff
- Revenue cycle teams
Codes Discussed
Modifiers Discussed
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