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
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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