# ? OB ultrasound codes or non???



## Kimberley (Sep 21, 2010)

ENDOVAGINAL AND TRANSABDOMINAL PELVIC ULTRASOUND, 09/14/10

COMPARISON EXAMS:  None.

CLINICAL INDICATION:  29-year-old female with history of elevated beta HCG status post 
right salpingectomy in Hawaii three weeks ago with no decidual tissue seen in the 
pathologic sample and with steadily slowly rising beta HCG levels up to the approximately 
400s recently. Evaluate for ectopic pregnancy. 

TECHNIQUE:  Multiple transverse and longitudinal images through the pelvis were 
obtained transabdominally and endovaginally with additional supplemental color flow 
imaging. Permanent images were recorded.  

DISCUSSION:  Within the cervix, there is a 1.1 x 0.7 x 0.9 cm simple cystic lesion without 
significant increased vascularity surrounding it and with no associated decidual response 
of the endometrium. This likely represents a simple nabothian cyst. A cervical ectopic is 
unlikely but cannot be 100% excluded based on this exam. The remainder of the uterus is 
normal in appearance. No myometrial or endometrial abnormalities are seen with the 
endometrium measuring 3 mm in thickness. The uterus is retroflexed. No distinct 
abnormalities of the corneal regions of the uterus are distinctly identified. Within the left ovary which is distinctly separate from the adjacent uterus, there is a 
simple cystic structure measuring 0.7 x 0.6 x 0.7 cm with some increased vascularity 
surrounding the lesion but not within it. Although this likely represents normal follicle in 
this ovary, the possibility of an ovarian ectopic cannot be definitively excluded based on 
this exam. The right ovary is normal in appearance measuring 2.4 x 1.4 x 2.3 cm. No free fluid is 
seen in the pelvis.These findings were discussed with Dr. Ambani at the time of exam interpretation by


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## Kimberley (Sep 23, 2010)

Any help would be greatly appreciated


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## DoDCoder4You (Sep 23, 2010)

I would say non OB. It didnt state they saw a baby. If it did, I must have missed it.


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## Lisa Bledsoe (Sep 23, 2010)

*non-OB*

Obstetrical US codes state "pregnant uterus", "gestation", "fetus".  Since there is no apparent uterine pregnancy, no gestation/fetus noted, I would use non-OB US codes.


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