AMA Clinical Examples in Radiology - 2020 Issue 3 (Summer)
Double-Contrast Esophagram
CLINICAL EXAMPLE 2 Double-Contrast Esophagram CLINICAL DATA A 78-year-old female with dysphagia to pills and food. TECHNIQUE Scout radiographic images of the chest and upper abdomen were obtained. An esophagram was performed with dynamic and spot fluoroscopic images recorded in frontal, oblique, and lateral upright projections. The patient ingested thick barium followed by effervescent crystals. Subsequent prone position, right anterior oblique images were obtained with ingestion of thin barium. A 1.25-cm barium pill was ingested, and its passage was visualized fluoroscopically. FINDINGS Scout radiographic images demonstrate a tortuous course of the thoracic aorta and atherosclerotic calcification. There is...
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Article Overview
This article explains a radiology coding example for an esophageal fluoroscopic examination and discusses the related diagnosis coding, coverage context, and reporting considerations tied to fluoroscopy documentation and NCCI edits. It is useful for coders, radiology staff, and compliance professionals who need to understand the general scope of the study, the applicable code sets, and the coding context referenced by the example.
Why This Topic Matters
Understanding how this kind of esophageal imaging report is framed helps ensure the procedural and diagnosis coding context is recognized correctly, especially when fluoroscopy reporting and payer edit considerations are involved.
Article Sections
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Clinical Example 2
A brief patient scenario and imaging workup are presented to frame the coding example. The section provides the clinical context for the study.
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How to Code
This section presents the coding references associated with the example and identifies the related diagnosis codes. It also includes general discussion of the imaging study and reporting context.
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Discussion
General background is provided on esophageal imaging, code-set revisions, and reporting considerations related to fluoroscopy documentation. The section also references broader compliance and payer-edit topics.
What You Will Learn
- How the article frames an esophageal imaging example for coding review
- Which code sets are referenced in the coding discussion
- What general documentation and reporting topics are associated with the study
- How the article situates the example within radiology coding and compliance context
Who Should Read This
- Radiology coders
- Professional coders
- Billing staff
- Compliance teams
- Physicians and radiology practices
Codes Discussed
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