lundi 28 septembre 2015

Vesicoureteral reflux follow up U/S

Hello,
I'm new at radiology coding and second guessing myself.
Procedure: US Renal.
History: 22 month old female with a history of vesicoureteral reflux on rt, followup exam. History of previous surgical repair.
Technique: multiple transabdominal ultrasound images of bilateral kidneys and urinary bladder are submitted.
Impression: the bilateral kidney is within normal limits.
Right adnexal homogeneous echogenic mass

My question is should I code the primary diagnosis of V67.09 secondary as V13.09? Furthermore, should I add the incidental finding of the adnexal mass 625.8?

Also, do you feel it's warranted to code the complete ultrasound exam of 76770 or use the limited exam since it's stated as followup?
Thanks so much!!
April


Vesicoureteral reflux follow up U/S

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