Code this report as if you work for the hospital. Coding Hint: There are two dia
ID: 243760 • Letter: C
Question
Code this report as if you work for the hospital.
Coding Hint: There are two diagnosis codes, one Z code, one CPT code, and one modifier associated with this report.
ULTRASOUND OF THE PELVIS: There has been satisfactory gray-scale sonographic evaluation of the pelvic structures. There is a single intrauterine gestational sac with a single live intrauterine gestation identified with cardiac activity. The gestational age mean is 8 weeks. This is concordant with the gestational sac size and estimated gestational age by LMP of ___ [DATE]. Both ovaries are identified. The right ovary measures 31 x 27 x 20 mm and has a single 15-mm cyst likely representing corpus luteum. The left ovary is normal measuring 34 x 30 x 18 mm. There is no free fluid or hydronephrosis. No other abnormalities were seen.
IMPRESSION: Single live intrauterine gestation with a mean gestational age of 8.0 weeks by crown-rump length. Normal adnexa. No free fluid.
Explanation / Answer
The CPT code for ultrasound of pelvis, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester, transabdominal approach, single or first gestation is 76801.
The z code for person's encountering health services in circumstances related to reproduction is Z36.