AMA Clinical Examples in Radiology - 2008 Issue 2 (Spring)
Radiology Test Case
Radiology Test Case This radiology test case is provided for coding professionals to test their knowledge. Please take some time to review and code the case. Once you are confident with your answer, turn to page 9 for the correct answer and discussion. Clinical History 17-year-old female with acute right pelvic pain Procedure Transabdominal and transvaginal ultrasound imaging of the pelvis demonstrates a normal size, anteverted, antiflexed uterus measuring 8.5 × 4.2 × 5.1 cm (length × height × width). The contour of the uterus is smooth and the myometrium is normal in appearance without masses...
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Article Overview
This test-case article is designed for coding professionals and presents a pelvic ultrasound scenario with Doppler assessment in the setting of acute pelvic pain. It covers the clinical history, imaging findings, and the radiology impression in a way that supports code-selection practice and review of radiology documentation.
Why This Topic Matters
It helps readers assess how a pelvic ultrasound with Doppler is documented and how radiology coders recognize the scope of the exam in an acute emergency setting.
Article Sections
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Clinical History
Provides the patient context and presenting complaint that prompted the imaging study.
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Procedure
Describes the ultrasound examination and the Doppler evaluation of the pelvis and ovaries.
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Impression
Summarizes the radiology conclusion from the study.
What You Will Learn
- How the clinical context relates to pelvic ultrasound documentation
- What types of imaging components are included in a pelvic ultrasound study with Doppler
- How radiology reports present findings and impressions for a suspected gynecologic emergency
- How test-case radiology articles are structured for coding practice
Who Should Read This
- Radiology coders
- Coding auditors
- Clinical documentation improvement specialists
- Billing staff involved in imaging claims
- Coding educators and trainees
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