Wiki No definitive answer from MD...how would my fellow coders proceed?

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Procedure: Sonohysterogram
Patient was placed on the examining table in the dorsal lithotomy position. Transvaginal ultrasound was done and endometrium was noted to be
0.588 cm in A-P thickness. There continues to be a small fluid pocket at the fundus. Speculum was placed. Cervix and vagina were cleaned with
Betadine. A disposable HSG catheter was placed transcervically with instillation of 1 cc sterile saline into the catheter balloon. The speculum was
subsequently removed followed by placement of the transvaginal probe. Sterile normal saline was then injected into the uterine lumen using 2D & 3D
ultrasound visualization. The uterine lumen appeared to have irregularity consistent with polyps on both right and left uterine walls. The cross section
of her uterus appears to have portions of the anterior and posterior wall that have been resected, potentially at previous surgery. This could
correspond with the area of fluid noted on initial ultrasound, as the walls may not be able to come together completely. The balloon was then deflated
and removed. The patient appeared to tolerate the procedure well, without complications.
Impression: Irregularities on left and right uterine walls consistent with polyps. Fluid pocket and irregular cross-sectional view of the uterus. Will plan
for hysteroscopy, polypectomy. Patient will call with CD1 to schedule.
 
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