prashant01
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PELVIC ULTRASOUND
EXAM DATE: 1/2/2018 04:45 PM.
CLINICAL HISTORY: ENDOMETRITIS.
COMPARISON: 12/31/2017 pelvic ultrasound.
TECHNIQUE: Realtime transabdominal pelvic scan performed to identify the uterus and adnexa and as an overview of other pelvic structures, with static image documentation.
FINDINGS:
Uterus: 14.7 x 8.6 x 8.2 cm, volume 539.05 cc. Anteverted position. Heterogeneous echotexture. No fibroids.
Masses: None.
Endometrium: 38 mm. Heterogeneous with numerous punctate hyperechoic foci and scattered flow.
Cervix: Unremarkable.
Right Ovary: 3.0 x 2.5 x 2.1 cm, volume 8.2 cc. Normal echotexture and blood flow.
Left Ovary: Not seen
Free Fluid: None.
Other: None.
IMPRESSION:
1. Enlarged, postpartum uterus.
2. The endometrium remains heterogeneous and markedly thickened with scattered areas of flow suggesting retained products of conception and/or blood products. Endometritis not excluded.
3. Nonvisualization of left ovary. The right ovary is normal.
4. No free fluid within the pelvis.
how will code that scenario...asap
EXAM DATE: 1/2/2018 04:45 PM.
CLINICAL HISTORY: ENDOMETRITIS.
COMPARISON: 12/31/2017 pelvic ultrasound.
TECHNIQUE: Realtime transabdominal pelvic scan performed to identify the uterus and adnexa and as an overview of other pelvic structures, with static image documentation.
FINDINGS:
Uterus: 14.7 x 8.6 x 8.2 cm, volume 539.05 cc. Anteverted position. Heterogeneous echotexture. No fibroids.
Masses: None.
Endometrium: 38 mm. Heterogeneous with numerous punctate hyperechoic foci and scattered flow.
Cervix: Unremarkable.
Right Ovary: 3.0 x 2.5 x 2.1 cm, volume 8.2 cc. Normal echotexture and blood flow.
Left Ovary: Not seen
Free Fluid: None.
Other: None.
IMPRESSION:
1. Enlarged, postpartum uterus.
2. The endometrium remains heterogeneous and markedly thickened with scattered areas of flow suggesting retained products of conception and/or blood products. Endometritis not excluded.
3. Nonvisualization of left ovary. The right ovary is normal.
4. No free fluid within the pelvis.
how will code that scenario...asap