CPT for Survey Sonographic Exam?? Huh?

she803

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Not sure which CPT to code for documentation below:

Clinical History: Bilateral leg pain.

Comments: Survey sonographic examination bilateral popliteal fossa.

On the left, there is a bilobed complex cystic lesion containing internal echoes in the medial aspect of the popliteal fossa. There are 2 components, measuring 3.7 x 1.6 x 1.5 cm and 1.8 x 1.8 x 1.9 cm. On the right, there is an ovoid cystic lesion in the medial aspect of popliteal fossa measuring 4.1 x 1.5 x 2.5 cm. These probably represent popliteal cysts, the left more complex. Cystic soft tissue masses also considered although felt less likely.

Color-flow identified in both popliteal artery and vein, as well as compression of the popliteal vein.

Impression: Cystic lesions in both popliteal fossae, as described.


Thank you in advance,

S. Huland El, CPC

Radiology Coding Specialist
 
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BRBS

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As you have Cystic lesions in both popliteal fossae, 727.51 will override 729.5. My apololgies for the confusion:)
 
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