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reginacoder

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As a CPC -A I need a little help in getting started in the right direction: Radiology Coding

Patient has a history of hysterectomy and rt oophorectomy for a rt ovarian torsion. A US pelvis non OB was done - 76856. US endovaginal scan was done 76860. The Impressions after radiology test/scan were as follows: 1. Uterus and rt ovary have been removed. 2. The lt ovary appears normal. and 3. no significant lesions are seen. What is the dx code ?

Would appreciate your guidance.
 

cjacobs

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What is the reason for encounter, just cause she has a history of does not mean that is the reason for the encounter. Patient could have had these items remove years ago which would not apply to the visit. If this exam is postoperative per the ovarian torsion then I would use the codes V88.01,V45.77 and 620.5.
 

mitchellde

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What is the reason for encounter, just cause she has a history of does not mean that is the reason for the encounter. Patient could have had these items remove years ago which would not apply to the visit. If this exam is postoperative per the ovarian torsion then I would use the codes V88.01,V45.77 and 620.5.
Again V45.77 EXCLUDES the use of V88.01, meaning you may code one or the other but never both. And you would never code an acute problem that currently does not exist. The posted stated the patient had had a rt oophorectomy which means there can not be a current ovarian torsion on the RT side and it was not stated that she has one on the left side. I did assume this was a post op encounter but you are correct in that I should not have assumed this, it does come down to the reason for the encounter. But you can never code the preoperative diagnosis as the reason for a post op encounter if the surgery corrected the issue. This is the patient's diagnosis not the physicians.
 

preserene

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My humble openion is this:
The reason for the screening (Ultrasound) this time, is to verify whether the left ovary which is the only ovary there, is deseased or not.
It looks as though the ultrasound is not for the follow up of the status of the post surgical uterus or right ovary operated already.
The findings documented is only about the left ovary whether diseased or not.
After ultrasound screening the left ovary seems normal and no torsion.

So I feel like leaning on to V71.8 as the prim listed and 81.6 as a supporting diagnosis.
Would it be Ok?
Thank you
 
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