Wiki Poc ob us

LeaHarris

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Is anyone familiar with this type of ultrasound? We are a family practice clinic and have a small bedside ultrasound machine in house that we just starting using. I am not sure what is appropriate for a CPT code. Sometimes we just have a note from the provider indicating a POC US was used while other times the report is actually sent to the radiologist for a report. Here is an example:

POC US - Breech, FHR 140s, placenta posterior, +fetal limb movements. Greatest fluid pocket 4.3cm.
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PROCEDURE: ULTRASOUND OBSTETRICAL SECOND/THIRD TRIMESTER
INDICATIONS: anatomical survey.
COMPARISON: Ultrasound 3/2/2018
HISTORY: Gravida
LMP: 10/30/2017; EGA by LMP: 23 weeks, 0 days;
SUMMARY OF PREVIOUS ULTRASOUNDS:
DATE: 3/2/2018: EGA by LMP: 17 weeks 4 days; EGA by 1st US: 16 weeks 2 days;
EDD
by US: 8/15/2018
Findings: None
BIOMETRY:
BPD: 49 mm; 21 weeks, 0 days
HC: 181 mm; 20 weeks, 4 days
AC: 171 mm; 22 weeks, 1 days
FL: 38 mm; 22 weeks, 1 days
HC/AC Ratio: 1.06
Cephalic Index: 77.5
Fetal Weight: 459.2; % of LMP: 22.9
EDD by US: 8/17/2018; AVG EGA: 21 weeks, 3 days
SONOGRAPHIC ASSESSMENT
TYPE OF GESTATION: Single
PRESENTATION: Variable
PLACENTAL LOCATION: Posterior
PLACENTAL EDGE: Clear of internal os - greater than or equal to 2 cm
PLACENTAL CORD INSERTION: Central
FETAL GROWTH: Normal
HEART RATE: 156 bpm
AMNIOTIC VOLUME: Normal
AFI: 12.4
FETAL ORGAN ASSESSMENTS
FOUR-CHAMBER HEART: Normal; RVOT: Normal; LVOT: Normal
LATERAL VENT: Normal 3.9 mm; CISTERNA MAGNA: Normal 4.0 mm;
STOMACH: Normal
KIDNEYS: Normal
BLADDER: Normal
3-VESSEL CORD/CORD INSERTION: Normal
FETAL SPINE: Normal
EXTREMITIES: Normal
NOSE/LIPS: Normal
PROFILE: Normal
MATERNAL STRUCTURES
CERVIX: Not adequately seen
UTERUS:Findings, 4.0 cm. Hypoechoic mass.; ADNEXA: No findings.
COMMENTS: Redemonstration of subserosal exophytic fibroid arising from the
posterior uterine body. It is not significantly changed in size, measuring
approximately 4.0 cm on todays ultrasound, previously 4.3 cm.
IMPRESSION:
1**Single living intrauterine pregnancy. EGA by todays ultrasound is 21 weeks
and 3 days, 1 week and 4 days behind the EGA by LMP. This remains within
accepted variance and growth is in the 23rd percentile based on the LMP.
2.**Normal fetal anatomy survey with no fetal anomalies detected. Both hands
are
identified, though the fingers were incompletely evaluated due to closed
positioning of the hands during much of the examination.
3.** Posterior placenta without evidence of previa. Central cord insertion.
4.**Normal amniotic fluid volume.
Transcribed by: MM at 4/9/2018 4:24 PM
Electronically signed by: Matthew Bentz, MD on 4/9/2018 6:14 PM at workstation
CS-274-7704
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Thank you!
 
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