These lie subjacent to the supraspinatus insertion. What CPT ® and ICD-10-CM codes are reported by the facility?Įxam: MRI right upper extremity joint W/O contrast Admitting Diagnosis: RT shoulder pain Indication: Right shoulder pain and numbness no comparison study Result: There are a few small subchondral cysts in the humeral head adjacent to the greater tuberosity. No discrete abnormality was seen in the internal auditory canals. Specifically, there is a 7 mm focus in the left CP angle which is probably the cause of the patient's left facial palsy. Multiple lesions were also seen in the brain stem and the brachium pontis. There has been a fairly significant increase in the number of lesions since the last exam. Impression: Multiple hyperintense lesions predominately in the periventricular white matter with characteristic pattern for MS. This would correlate with the patient's symptoms of a left facial palsy. No abnormal signal, enhancement of discrete mass lesion is appreciated within the internal auditory canals. There is a 7 mm focus of increased signal at the left CP angle. There is no edema or mass effect from the lesions. There are multiple punctuate areas of hyperintense signal in the brain stem and brachium pontis. The pituitary gland and cerebellum are unremarkable. The pattern and distribution is most characteristic for MS. The enhancement seen previously has resolved. With contrast enhancement, none of the plaques appear to enhance at this time. Since the prior exam, there has been an increase in the number of hyperintense plaques. Many of the foci are elongated and oriented toward the ventricles. There are multiple punctuate areas of abnormal increased T2 weighted signal in the periventricular white matter and in the subcortical white matter of the centrum semiovale. There are no extra-axial fluid collections. There is no evidence of mass effect or midline shift. The ventricles and sulci are within normal limits. The old study was available for comparison. Sagittal T1 weighted and high resolution coronal and axial pre- and post-Gadolinium images of the internal auditory canals were obtained. Axial T1 weighted pre- and post-Gadolinium (1.6 mL) (iron-based contrast), T2 weighted FLAIR, and diffusion images were obtained. Left facial weakness in a patient w/hx of Bell's Palsy and MS Result: MRI of the brain was obtained at 1.5 Tesla. Rhinology: Disorders of the nose and sinuses.Exam: MRI brain W/O and W contrast Admitting Diagnosis: Left facial weakness/Bell's palsy Clinical History: Comparison.Examples: tonsil and adenoid infection, airway problems, Down's syndrome Pediatric Otolaryngology: Diseases in children with special ENT problems including birth defects in the head and neck and developmental delays.Examples: ear infection, hearing loss, dizziness Otology and Neurotology: Diseases of the ear, including injury, cancer, and nerve pathway disorders, which can affect the ear and balance.Examples: sore throat, hoarseness, swallowing disorder Laryngology: Disorders of the throat, including voice and swallowing problems.Examples: lump in the neck or thyroid, cancer of the voice box Head and Neck: Cancerous and noncancerous tumors in the head and neck, including the thyroid and parathyroid.Examples: deviated septum, rhinoplasty, cleft palate Facial Plastic and Reconstructive Surgery: Cosmetic, functional, and reconstructive surgical plastic treatment of abnormalities of the face and neck.Examples: hay fever, seasonal and perennial rhinitis Allergy: Treatment by medication, immunotherapy (allergy shots) and/or avoidance of pollen, dust, mold, food, and other sensitivities that affect the ear, nose, and throat.
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