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Wiki Vesicoureteral reflux follow up U/S

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aprilz0705

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Hello,
I'm new at radiology coding and second guessing myself.
Procedure: US Renal.
History: 22 month old female with a history of vesicoureteral reflux on rt, followup exam. History of previous surgical repair.
Technique: multiple transabdominal ultrasound images of bilateral kidneys and urinary bladder are submitted.
Impression: the bilateral kidney is within normal limits.
Right adnexal homogeneous echogenic mass

My question is should I code the primary diagnosis of V67.09 secondary as V13.09? Furthermore, should I add the incidental finding of the adnexal mass 625.8?

Also, do you feel it's warranted to code the complete ultrasound exam of 76770 or use the limited exam since it's stated as followup?
Thanks so much!!
April
 
April:
Since the diagnostic statement shows bilateral kidneys and bladder were performed, I would use the 76770 (documentation will support). I would use the V67.00 as opposed to V67.09 for the follow-up after surgery (look at the description of procedures listed for V67.09). Also, if the physician documented the diagnosis on the chart as a finding, then yes you can code the Adnexal mass as a secondary code. I would not however, code the V13.09 as a diagnosis code.
Hope this helps :)
 
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