Wiki Radiology help with coding this

[bluestar9]

Exam: Ultrasound of the Native Kidneys

Findings:
Ultrasound examination of the kidneys was performed in this post transplant patient.

The Right Native Kidney measures 5.6 x 3.0 cm in size. A probable 8 mm cyst is present. No mass or hydronephrosis is currently identified

The Left Native Kidney measures 8.7 x 4.1 cm in size. A probable cyst measuring 9 mm is present.

A transplant kidney is noted in the RLQ

The bladder is unremarkable

Conclusion:
No significant abnormality demonstrated on today's examination

 

[whatwouldyousay]

What is the indication?

 

[thomas7331]

Hi Bluestar9
You could code this xray from the results as dx N28.1 and Z13.0 or code it R93.42.
I hope helped you.
Lady T

None of those codes is supported by the documentation. I have no idea how you're coming up with these.

I agree with the post above that you would need to know the indication for the procedure in order to properly code this. There are no abnormalities documented and it's unclear why this ultrasound was ordered. It could be follow-up care from the transplant, but that isn't stated in the note here so it can't be assumed.

 

[TThivierge]

Hi Thomas
I did not read the last sentence...you are correct.
Lady T