# Ultrasound Abdomen documentation



## jmizzer (Jan 25, 2013)

I have a question on the documentation in this report for a complete Abdominal U/S. The Dr. wants to bill a complete and I didn't agree with his description for the IVC and Aorta and would love some ideas. If anyone has anything in writing I can give him in black and white that would be great! He is stating the sentence " There is no evidence of aneurysm. Retroperitoneal Vasculature appears within normal limits that the "Retroperitoneal Vasculature" means the IVC and Aorta. A couple girls I work with and myself think this could be many structures in this area and not just the Aorta and IVC.  Help please! 

Examination:  US ABDOMEN
Exam Date:    01/18/2013

CLINICAL HISTORY: Thrombocytopenia and history of hepatic steatosis
evaluate for splenomegaly

Real time ultrasound examination was performed in order to evaluate the
liver, spleen, gall bladder, common bile duct, pancreas, kidneys, aorta and
inferior vena cava.  Color Doppler and Spectral Waveform imaging was
performed in order to characterize the pattern and directional flow in the
arteries and veins and to assess  for abnormal vascularity in regions of
interest, as requested.

The liver appears enlarged and increased in echogenicity, consistent with a
fatty liver. No discrete focal mass is identified. No bile duct dilation is
identified.

No gallstones are evident.

The CBD measures 5 mm which is within normal limits.

Imaging of the kidneys is unremarkable.

The spleen is enlarged measuring 18.5 cm. It appears homogeneous in
echotexture.

There is no evidence of aneurysm. Retroperitoneal vasculature appears
within normal limits.

Color Doppler and spectral waveform imaging of the upper abdomen show
patency of the vasculature. No flow related abnormality is detected.

IMPRESSION:

Splenomegaly

Increased size and increased echogenicity the liver. This is consistent
with hepatic steatosis.

No evidence of gallstones or bile duct dilation.


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## bevann0402@bellsouth.net (Jan 25, 2013)

someone may have written documentation, but based on a Radiology Business Manager's Meeting I attended, the presenter said in order to code a 76700 (complete) you have to mention all.  In all the ones I code, the radiologist specifically say aorta and IVC, along with all the other organs.

I agree with you, but it will be great to see what someone has to offer that has coded radiology longer than me.

Bev


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