AMA Clinical Examples in Radiology - 2016 Issue 2 (Spring)
Radiology Test Case
RADIOLOGY TEST CASE The radiology test case is provided for coding professionals to test their knowledge. Please take some time to review and code the case. Consider your answers as to how the procedure is reported in 2016. Once you are confident with your answer, turn to page 12 for the correct answer and discussion. Conversion of Bilateral Nephrostomies to Bilateral Ureteral Stents PROCEDURE Conversion of Bilateral Nephrostomy Tubes to Bilateral Ureteral Stents CLINICAL HISTORY Bilateral ureteral stenosis in a preexisting ileal conduit INDICATION Internalize bilateral percutaneous nephrostomy tubes TECHNIQUE After informed consent was obtained and a time-out performed...
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Article Overview
This article presents a radiology coding test case for professionals reviewing a bilateral urinary tract intervention in a patient with an ileal conduit. It is designed to help readers assess how the procedure would be reported in 2016 and includes the clinical history, technique, and study impression needed to understand the scenario. The piece is useful for coders working with interventional radiology and urinary diversion-related procedures, as well as those studying how to code complex conversion procedures.
Why This Topic Matters
It helps coding professionals evaluate a real-world-style radiology scenario involving bilateral nephrostomy management and internalization to ureteral stents in a diverted urinary tract. The article supports review of procedure reporting concepts for radiology cases from the 2016 timeframe.
Article Sections
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Conversion of Bilateral Nephrostomies to Bilateral Ureteral Stents
Introduces the procedure scenario and frames the case as a coding review exercise. This section establishes the overall intervention and the context for the radiology report.
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Procedure
Summarizes the bilateral intervention performed during the encounter. It provides the procedural context before the detailed imaging narrative.
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Clinical History
Describes the underlying urinary tract history and the presence of a urinary diversion. This section provides the clinical background relevant to the case.
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Indication
States the reason the procedure was performed. It identifies the general treatment goal for the encounter.
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Technique
Presents the procedural narrative for both sides, including access, imaging, device exchange, and confirmation steps. The section is written as a detailed radiology technique report.
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Impression
Provides the concluding summary of the radiology findings and procedural result. It restates the overall outcome in brief form.
What You Will Learn
- How a radiology coding case study is structured
- What clinical information is included in a procedural radiology report
- How bilateral urinary drainage interventions are documented in a training case
- How 2016-era reporting context is presented in a coding example
Who Should Read This
- Radiology coders
- Interventional radiology coding professionals
- Coding educators
- Coding students reviewing radiology case examples
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