Radiology Coding Alert

You Be the Coder:

Which Code for This US Case?

Published on Mon Jul 04, 2011

Question: How should I code this report? Real time gray scale evaluation was performed using endovaginal approach for improved visualization of the adnexal structures. Imaging over the uterus and adnexal regions bilaterally was performed.

Results: The uterus measures 7.4 x 4 x 5.4 cm in size. The endometrial canal measures 0.34 cm. Multiple fibroids are suggested within the fundus. The cervix has nabothian cysts present. The right ovary measures 3.6 x 2 x 2.5 cm in size. Follicles are also noted. The left ovary measures 2.75 x 2 x 2.2 cm in size. Follicles are noted.

Codify Member

Answer: Because the report indicates use of an endovaginal approach (another term for transvaginal) and the exam is nonobstetric, you should report 76830 (Ultrasound, transvaginal).

The report indicates the presence of nabothian cysts. The appropriate code for nabothian cysts is 616.0 (Cervicitis and endocervicitis).

Your report indicates fibroids are "suggested" but does not confirm them. ICD-9 guidelines tell you not to use codes for diagnoses documented with terms indicating uncertainty.

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