trisha_moore40@yahoo.com
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Can someone tell me their opinion regarding the documentation below if this would count as the common bile duct portion to bill for a complete exam - in my opinion it doesn't but maybe someone out there may know something I don't. It's the part regarding the extrahepatic duct and the extrahepatic biliary dilatation
PROCEDURE: US ABDOMEN COMPLETE
INDICATION: Right flank pain. History of ovarian cancer.
FINDINGS: The liver is homogeneous and exhibits normal echo texture. There is no focal hepatic abnormality. There is no intra or extrahepatic biliary dilatation. The extrahepatic duct is normal caliber at 3 mm.
The gallbladder is grossly normal and shows no evidence of cholelithiasis, gallbladder wall thickening or pericholecystic fluid.
Limited views of the spleen are normal. The head and body of the pancreas are normal. Renal cortical thickness and echogenicity are normal. The right kidney measures 11.0 cm and the left kidney measures 2.4 cm. There is no free fluid. The visualized abdominal vasculature is normal. Inferior vena cava where seen is normal caliber.
PROCEDURE: US ABDOMEN COMPLETE
INDICATION: Right flank pain. History of ovarian cancer.
FINDINGS: The liver is homogeneous and exhibits normal echo texture. There is no focal hepatic abnormality. There is no intra or extrahepatic biliary dilatation. The extrahepatic duct is normal caliber at 3 mm.
The gallbladder is grossly normal and shows no evidence of cholelithiasis, gallbladder wall thickening or pericholecystic fluid.
Limited views of the spleen are normal. The head and body of the pancreas are normal. Renal cortical thickness and echogenicity are normal. The right kidney measures 11.0 cm and the left kidney measures 2.4 cm. There is no free fluid. The visualized abdominal vasculature is normal. Inferior vena cava where seen is normal caliber.
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