1. Procedure and CPT® Code Selection:
The patient underwent venous thrombosis imaging of each leg to assess for deep venous thrombosis (DVT).
CPT® Code 78457 is used for a venous thrombosis imaging study. This code is appropriate for imaging to detect DVT.
Modifier 50 is applied to indicate a bilateral procedure, as imaging was performed on both legs.
2. Diagnosis and ICD-10-CM Code Selection:
ICD-10-CM Code I82.403 is used for acute embolism and thrombosis of unspecified deep veins of bilateral lower extremities. This code accurately describes the finding of DVT in both legs.
Other ICD-10-CM options, such as I82.401 and I82.402, specify unilateral lower extremity involvement, which does not accurately reflect the bilateral findings in this case.
3. Rationale for Excluding Other Options:
Code 78458 (in options A and D) is for a more comprehensive study, often cardiac or whole-body blood pool imaging, and is not specific to leg venous thrombosis.
Option C, which lists 78457 with individual RT and LT modifiers, is incorrect as Modifier 50 is appropriate for bilateral imaging on both legs.
4. AAPC and CPT® Coding Guidelines:
According to AAPC and CPT® guidelines, 78457 with Modifier 50 should be used for bilateral venous imaging studies, and I82.403 correctly captures bilateral DVT.
Thus, the correct answer is B. 78457-50, I82.403.
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