Forum - Questions & Answers

Oct 27th, 2013 - jjthekoolaid 3 

Need Help

1. RADIOLOGY REPORT
LOCATION: Outpatient, Hospital
PATIENT: Eric Tayes
ORDERING PHYSICIAN: Frank Gaul, MD
ATTENDING/ADMIT PHYSICIAN: Frank Gaul, MD
RADIOLOGIST: Morton Monson, MD
EXAMINATION: Ultrasound of both lower extremities; abdomen ultrasound.
CLINICAL SYMPTOMS: Lower extremity swelling, Respiratory distress.

FINDINGS: Ultrasound examination of the deep venous system of both lower extremities is negative. No evidence of deep venous thrombosis in either lower extremity. The posterior tibial, greater saphenous, and popliteal through femoral veins are patent and negative for thrombus bilaterally. Normal phasicity.

Abdomen Ultrasound: Diffusely coarsened echotexture of the liver with some nodularity consistent with fatty infiltration. Cirrhotic configuration of the liver. Small calcified granuloma in the spleen. The spleen is otherwise negative. There is ascites in all four quadrants. No bile duct dilatation. No gallbladder wall thickening or cholelithiasis. Small amount of fluid adjacent to the gallbladder is likely related to the ascites. The pancreas is obscured by bowel gas. The abdominal aorta is of normal caliber. The right kidney measures approximately 9 cm in length and shows no evidence of hydronephrosis, calculi, or mass. The left kidney measures approximately 9.9 cm in length and shows no evidence of hydronephrosis, calculi, or mass.

Which physician are you coding for?

Oct 27th, 2013 - katejohnson 11 

re: Need Help

Please remember to take the patients name off of the report when you ask a question.

You are coding for Morton Monson, MD; the radiologist.

Oct 27th, 2013 - jjthekoolaid 3 

re: Need Help

Thanks for the heads up and thank you

Oct 27th, 2013 - jjthekoolaid 3 

re: Need Help

If you don't mind can you explain to me how you got the answer



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