? correct CPT codes - PELVIC ULTRASOUND

Kimberley

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Nashville
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76856, 76830-59

or

76857, 76830-59


PELVIC ULTRASOUND (TRANSABDOMINAL AND ENDOVAGINAL)


INDICATION:
History of fibroids.


COMPARISON:
No priors.


TRANSABDOMINAL US FINDINGS:
The uterus is mildly enlarged measuring 11 x 4 x 5 cm. There are at least five uterine fibroids identified. The largest fibroid measures 7 cm and is located at the fundus. The other fibroids range from 2.4 x 4.6 cm in size. The endometrial stripe is not well visualized. There is a 1.9 cm hypoechoic mass within the upper aspect of the endometrial cavity, consistent with a pedunculated subserosal fibroid versus a polyp. The ovaries appear unremarkable. ENDOVAGINAL US FINDINGS: Uterine measurements are not accurately obtainable. Multiple uterine fibroids are redemonstrated. Again seen is an approximately 1.9 cm hypoechoic mass protruding into the upper aspect of the endometrial cavity, consistent with pedunculated submucosal fibroid versus polyp. The endometrial stripe is not well visualized due to the mass within the endometrial cavity.

There is normal blood flow to the ovaries.

The right ovary is normal and measures 2.6 x 1.6 x 1.8 cm. The left ovary is normal and measures 2.2 x 1.4 x 1.9 cm. There is no free fluid identified.

There is a nabothian cyst.


IMPRESSION:
1. Enlarged uterus with multiple fibroids. 1.9 cm mass within the upper aspect of the endometrial cavity, consistent with a pedunculated submucosal fibroid versus a polyp.

The endometrial lining is not well visualized as a result of this mass.

2. Normal appearance of the uterus
 

tonyacobb

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I would code 76856 and 76830-59.... Everything is imaged except for the bladder and according to the CSI Navigator, the bladder has to be imaged only "when applicable"... Hope this helps... :)
 
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