Ask Dr. Z

Would the following documentation be enough to charge conventional shoulder arthrogram and CT arthrogram separately? (Patient had CT shoulder arthrogram right after this contrast injection.)

"The patient was placed on fluoro table. The right shoulder was placed in external rotated position. Fluoro was utilized to select an approach to the medial margin of humeral head. A 22 gauge lumbar puncture needle was then advanced into joint space under fluoro guidance. Approximately 15 cc of omnipaque 300 was injected under fluoro, and needle was removed. Manipulation of the joint demonstrates contrast flowing into the superior subscapularis recess, indicating a full-thickness rotator cuff tear. IMPRESSION: Successful fluoroscopically-guided shoulder arthrogram."