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Radiology Report
Location: Hospital Outpatient
Patient: Dan Diel
Ordering physician: Daniel G. Olanka, MD
Radiologist: MOrton Monson, MD
Personal Physician: Ronald Green,MD
Examination: Gallbladder ultrasound
Clinical Symptoms: Increased bilirubin
Gallbladder Ultrasound: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6mm, and common bile duct measures 5.2mm. These valves are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.
Impression: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.

What is the name of the physician that you are coding for?
Identify the correct diagnosis (ICD-9_CM) code?
Using your CPT-4 manual, review the main term in the index and specify what code range is told to review in order to select the appropriate CPT code?
Identify the correct CPT-4 procedure (ICPT) codes(s) for the above scenario and modifier?

6. A patient presents to the laboratory at the clinic for the following tests: thyroid-stimulating hormone, comprehensive metabolic panel, and an automated hemogram with manual differential WBC count (CBC)

Identify the correct procedure (CPT-4) code for this service?


An 80 yr old woman female patient with cushing's syndrome presented to the laboratory for a lipid panel that includes measurement of total serum cholestrerol, lipoprotein (direct measurement, HDL and LDL), and triglycerides.

Identify the correct diagnosis (ICD-9-CM) code for the above scenario?

Identify the correct procedure (CPT-4-) codes for the above scenario?


A physician prescribes digoxin for treating a patient diagnosed with congestive heart failure. After six months, the physician performs a therapeutic drug test to monitor the level of the drug on the patient.

Identify the correct diagnosis (ICD-9-CM) code(S) for the above the scenario?

Identify the correct procedure (CPT-4) code(s) for the above the scenario?

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