AMA Clinical Examples in Radiology - 2004 Issue 1 (Winter)
Coding Transabdominal and Transvaginal Ultrasounds of the Pelvis
Coding Transabdominal and Transvaginal Ultrasounds of the Pelvis Ultrasound is a commonly used imaging modality for evaluation of the abdomen and pelvis. This case highlights the use of both transabdominal and transvaginal pelvic sonography in a nonpregnant female with chronic persistent lower abdominal and pelvic pain. Indication Left lower quadrant abdominal and pelvic pain in a 35-year-old female Requested Exam or Procedure Ultrasound of the pelvis Procedure Transabdominal pelvic ultrasound Report 76856 Ultrasound scans of the pelvis were performed transabdominally through a distended urinary bladder. The bladder is smooth in luminal contour and contains no filling defects. The uterus...
Subscribe or sign in to view the full article.
Article Overview
This article reviews a pelvic ultrasound case involving both transabdominal and transvaginal imaging in a nonobstetric setting. It focuses on how the exam is documented and categorized, and it includes discussion of related CPT ultrasound section guidance, historical updates, and references to professional coding resources. The piece is aimed at coders, billers, and clinicians working with diagnostic ultrasound reporting.
Why This Topic Matters
Pelvic ultrasound coding can vary depending on whether the study is complete or limited, whether imaging is transabdominal or transvaginal, and whether the setting is obstetrical or nonobstetrical. This article helps readers understand the scope of the exam and the general documentation themes that affect code selection.
Article Sections
-
Indication
States the presenting symptoms and patient context for the imaging request.
-
Requested Exam or Procedure
Identifies the ultrasound service being requested.
-
Procedure
Describes the initial imaging approach and the corresponding report material.
-
Impression
Summarizes the general findings from the initial study.
-
Procedure
Describes the follow-up imaging approach and report material from the second study.
-
Impression
Summarizes the general findings from the follow-up study.
-
How to Code
Presents the coding summary for the case and the associated ultrasound categories referenced in the article.
-
Coding Tip
Provides general guidance on selecting pelvic ultrasound codes in relation to exam scope and documentation.
-
Dicussion
Reviews broader considerations for transvaginal and pelvic ultrasound coding, including obstetrical and nonobstetrical contexts.
-
Coding Advice
Offers additional general notes on documenting and reporting pelvic ultrasound examinations.
-
Coding Tip
Summarizes cross-reference guidance and general documentation considerations for combined ultrasound studies.
-
Footnote
Lists source references and publication information.
What You Will Learn
- How the article frames a combined pelvic ultrasound case for coding review.
- What broad documentation themes are discussed for complete and limited pelvic ultrasound studies.
- How the article distinguishes transabdominal and transvaginal imaging in general coding context.
- Which reference materials and professional resources are mentioned in connection with pelvic ultrasound coding.
Who Should Read This
- Medical coders
- Radiology billers
- Compliance staff
- Diagnostic imaging clinicians
- Revenue cycle professionals
Codes Discussed
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com
