AMA Clinical Examples in Radiology - 2009 Issue 2 (Spring)
Radiology Test Case
Radiology Test Case This radiology test case is provided for coding professionals to test their knowledge. Please take some time to review and code the case. Once you are confident with your answer, turn to page 8 for the correct answer and discussion. Clinical History A 66-year-old male patient was referred for evaluation of a hepatic vascular malformation and mesenteric ischemia with CT angiography. CT technologists and nurses were unable to establish intravenous (IV) access for power injection, and a request was made for ultrasound-guided access. Procedure Ultrasound-guided IV access requiring physician skill Procedure Under usual aseptic conditions and...
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Article Overview
This article presents a short radiology coding test case intended for coding professionals. It covers a clinical scenario involving vascular imaging workup, ultrasound-guided IV access, and a brief procedure report, making it relevant for readers reviewing radiology documentation and code selection concepts.
Why This Topic Matters
It helps radiology coding professionals and auditors understand how a documented imaging-guided access procedure is presented in a test-case format and what information is included in the report.
Article Sections
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Clinical History
Provides the patient context and the reason the imaging-related evaluation was requested.
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Procedure
Summarizes the access-related procedure and the general circumstances under which it was performed.
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Technique
Describes the imaging findings and technical notes related to the access site and vessel assessment.
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Impression
States the overall outcome of the procedure in brief form.
What You Will Learn
- The type of radiology scenario presented in this coding test case
- How the report is organized into history, procedure, technique, and impression
- What general documentation elements are included in an ultrasound-guided access case
- Why this type of case is relevant to radiology coding review
Who Should Read This
- Radiology coding professionals
- Medical coders
- Coding auditors
- Radiology documentation reviewers
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