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? OB ultrasound codes or non???

  1. #1
    Default ? OB ultrasound codes or non???
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    CLINICAL INDICATION: 29-year-old female with history of elevated beta HCG status post
    right salpingectomy in Hawaii three weeks ago with no decidual tissue seen in the
    pathologic sample and with steadily slowly rising beta HCG levels up to the approximately
    400s recently. Evaluate for ectopic pregnancy.

    TECHNIQUE: Multiple transverse and longitudinal images through the pelvis were
    obtained transabdominally and endovaginally with additional supplemental color flow
    imaging. Permanent images were recorded.

    DISCUSSION: Within the cervix, there is a 1.1 x 0.7 x 0.9 cm simple cystic lesion without
    significant increased vascularity surrounding it and with no associated decidual response
    of the endometrium. This likely represents a simple nabothian cyst. A cervical ectopic is
    unlikely but cannot be 100% excluded based on this exam. The remainder of the uterus is
    normal in appearance. No myometrial or endometrial abnormalities are seen with the
    endometrium measuring 3 mm in thickness. The uterus is retroflexed. No distinct
    abnormalities of the corneal regions of the uterus are distinctly identified. Within the left ovary which is distinctly separate from the adjacent uterus, there is a
    simple cystic structure measuring 0.7 x 0.6 x 0.7 cm with some increased vascularity
    surrounding the lesion but not within it. Although this likely represents normal follicle in
    this ovary, the possibility of an ovarian ectopic cannot be definitively excluded based on
    this exam. The right ovary is normal in appearance measuring 2.4 x 1.4 x 2.3 cm. No free fluid is
    seen in the pelvis.These findings were discussed with Dr. Ambani at the time of exam interpretation by

  2. #2
    Any help would be greatly appreciated:-)

  3. #3
    I would say non OB. It didnt state they saw a baby. If it did, I must have missed it.

  4. #4
    Greeley, Colorado
    Default non-OB
    Obstetrical US codes state "pregnant uterus", "gestation", "fetus". Since there is no apparent uterine pregnancy, no gestation/fetus noted, I would use non-OB US codes.
    Lisa Bledsoe, CPC, CPMA

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