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OB SONO LESS THAN 14WKS

Minerva Posted Mon 13th of June, 2011 22:52:46 PM

clinical history:pelvic pain.vaginal bleeding.declinis seral beta HCG. Technique:real tiem gray scale evaluation was performed using transabdominal approach over the pelvis. for improved visualization of the adnexal structures, endovaginal probe was used as well. LMP: 4/1/2011, Gravida 4,Para:3,HCG:positive,HCG value: 99.77. gestational sac visualized?no. uterine measuremments: 8.9 x 4.2 x 7.4 cm, Endometrial canal: 1.45,cervicl lenght: moren than 3cm,internal cervical Os:closed,right ovary:2.3x1.4x2.8cm,right ovarian cyst:simple 0.9x0.8x.9cm,left ovary:not visualized,cul de sac fluid:none...no intrauterine gestational sac is demonstrated. there is a complexx.3cmx1.9cmx2.0cm collection/lesion within the cervice. there is not sign of adnexal mass or lesion.in the setting of declining serial beta HCG and presence of cervical collection, the findings most compatible with retained products of conception in setting of pregnancy loss. ectopic pregnancy is not completely excluded..would I code as 76801 or 76815?

Thank You.

SuperCoder Answered Tue 14th of June, 2011 13:33:14 PM

I think 76801 & 76817 both should be used in this case for transabdominal and transvaginal approach(if indications is for OB sono). For non-OB use 76856 & 76830.

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