Wiki Please help in fionding the ICD 9 code

[dha_coder]

Reason For Exam: abdomen pain

REPORT: PREGNANCY ULTRASOUND:

INDICATIONS: Abdominal pain, ectopic pregnancy.

FINDINGS:

The uterus measures 9 x 5.8 x 5.3 cm, retroverted. The endometrium measures 1.3 cm. A small cystic structure is seen 0.09 x 0.2 x 1.7 cm, nonspecific. The right adnexa measures 3.2 x 2.97 x 2.8 cm with a cyst of 2 x 2.1 x 2 cm,
with an echo seen. Could be a corpus luteal cyst. The left ovary measures 2.3 x 1.9 x 1.7 cm.

Arterial and venous flow to the bilateral adnexa. Pelvic free fluid. Small cyst in the region of the cervix. Pelvic varices.

IMPRESSION:

1. No convincing intrauterine pregnancy is defined. Possibility of a very early pregnancy, abortion, ectopic. Correlation with beta-hCG and follow-up, would be recommended to assess interval growth and development.
2. Adnexal cyst could be a corpus luteal cyst.
3. Flow to bilateral adnexa.
4. Pelvic varices. Correlate clinically with symptoms of pelvic congestion.
5. Small cyst, with calcifications, in the cervical region.
6. Pelvic free fluid could be reactive or inflammatory.
7. Follow-up and correlation with beta-hCG recommended.

 

[dha_coder]

One of our coder suggest 633.90 as a Pdx, Please validate.

Any suggestion will be appreciated.

Thanks in advance.

 

[mitchellde]

You cannot code an ectopic pregnancy since it is documented as possible, the findings show that this is a cyst. That is what you can code.

 

[zoting.arvind@gmail.com]

can we code an ob cpt 76815 even there is no gestation is confirmed and can we code a non-ob ultrasound chart with header 76856 have pregnancy confirmed in indication.