AMA Clinical Examples in Radiology - 2006 Issue 4 (Fall)
MRI Pelvis Procedure Without and With Contrast
MRI Pelvis Procedure Without and With Contrast Clinical History Symptomatic uterine fibroids MR Technique Sagittal, oblique coronal, and oblique axial T2-weighted fast spin-echo, oblique 72197 Q9952 axial T1-weighted spin-echo imaging was obtained without contrast followed by an oblique axial T1-weighted postgadolinium spin-echo imaging of the pelvis. MR Findings There are multiple fibroids within the uterus demonstrating low signal on T1 and T2-weighted sequences. No significant increased T2 signal is present within the fibroids to suggest internal degeneration. There is a lobulated, submucosal fibroid within the right anterior fundus that extends into the endometrial cavity and measures approximately 5.1...
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Article Overview
This article reviews a pelvic MRI clinical example centered on uterine fibroids and a likely functional ovarian cyst, then explains the associated coding context for reporting the imaging study and contrast agent. It is intended for coders, radiology staff, and revenue cycle professionals who need to identify the relevant procedure category, understand the general documentation context, and distinguish the article’s coding discussion from the clinical findings.
Why This Topic Matters
Pelvic MRI studies are common in gynecologic evaluation, and correct reporting depends on recognizing the imaging approach, contrast use, and the applicable procedure and supply codes. The article also places the example in the broader context of fibroid workup and radiology coding updates, making it useful for accurate claim preparation and compliance.
Article Sections
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Clinical History
Introduces the patient context and the reason the pelvic MRI was performed.
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MR Technique
Summarizes the imaging approach used for the pelvic MRI study and the sequence setup described in the case example.
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MR Findings
Presents the main imaging observations from the pelvis exam, including the general categories of pelvic structures evaluated.
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Impression
Provides the radiologist’s overall interpretation of the pelvic MRI findings.
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How to Code
Explains the general coding context for reporting the MRI study and associated contrast agent.
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Discussion
Offers broader coding and clinical context about pelvic MRI use, fibroid evaluation, and related radiology guidance.
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Coding Tips
Highlights coding context related to uterine fibroid embolization and the separate reporting of diagnostic MRI studies.
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Endnote
Lists source references and practice guidance related to pelvic MRI performance.
What You Will Learn
- What the article covers in a pelvic MRI case example
- How the article frames the relationship between the exam and coding support material
- What broader pelvic MRI and gynecologic imaging context the discussion includes
- Which professional guidance and reference types are mentioned
Who Should Read This
- Medical coders
- Radiology coders
- Revenue cycle staff
- Radiology documentation staff
- Compliance professionals
Codes Discussed
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