LOCATION: Outpatient,Hospital PATIENT: JuliaOlivia ORDERINGPHYSICIAN: RonaldGree

Question

LOCATION: Outpatient,Hospital PATIENT: JuliaOlivia ORDERINGPHYSICIAN: RonaldGreen,MD RADIOLOGIST: MortonMonson,MD PELVIC TRANSABDOMINAL SONOGRAM AND ABDOMEN COMPLETE SONOGRAM HISTORY: Chronicabdominalpain PELVIC AND TRANSABDOMINAL STUDY: The uterus measures 7.1 3 4.7 3 3.3 cm. The endometrial stripe measures 0.6 cm in thickness. The right ovary measures 1.8 3 2.5 3 2.1 cm and the left ovary measures 2.5 3 1.2 3 2.3 cm. No obvious mass is noted in the adnexal regions, although there is a hypoechoic focus adjacent to the right ovary that does not demonstrate flow within it and may be due to small amount of free fluid surrounding it or is perhaps a prominent fallopian tube. Since transvaginal images were not submitted, this is incompletely evaluated. ABDOMINAL SONOGRAM: The aorta is of normal caliber. The pancreatic head and body are normal. The liver is normal. The gallbladder demonstrates dependent echoes with no evidence of shadowing stones. There is no wall thickening. No ductal dilatation. The common hepatic and common bile duct measure 0.2 and 0.3 cm, respectively. No free fluid in Morison’s pouch. The right kidney is normal in length at 8.8 cm and the left kidney measures 9.6 cm in length. No evidence of hydronephrosis bilaterally. One of the following codes is reported incorrectly for this case. Indicate the incorrect code.

PROFESSIONAL SERVICES: Pelvic ultrasound, 76856-26; Abdomen ultrasound, 76700-26

ICD-10-CM DX: Abdominal pain, R10.84

INCORRECT CODE:

Explanation / Answer

Incorrect code: 76856-26

This code is incorrect as it is used for complete pelvic and transabdominal ultrasound, whereas, in this case the sonogram is incomplete.

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