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Below is the sample report please advice which CPT® and DX needs to be billed ? Please Help?
FIRST TRIMESTER OBSTETRICAL SONOGRAM:
LMP: 2/19/15. Expected gestational age of 9 weeks and 1 day.
The uterus measures approximately 9.6 cm in length x 5.4 cm A.P. x.2 cm in width containing a single intrauterine gestation. No fetal cardiac activity was detected. There are low-level internal echoes within the gestational sac. The mean crown rump length measures 1.4 cm, corresponding to an approximate gestational age of 7 weeks and 5 days. The mean gestational sac diameter measures 3.1 cm, corresponding to an approximate gestational age of 8 weeks.
There are multiple fibroids including a 1.5 x 1.2 x 1.7 cm posterior subserosal, a 1.6 x 0.9 x 1.3 cm anterior intramural, a 1.1 x 1.5 x 1.3 cm right posterior pedunculated and a 1.8 x 1.3 x 1.6 cm posterior intramural with slight subserosal extension.
The ovaries are normal in size and in echogenicity. The left ovary measures 1.5 x 1.9 x 3 cm. The right ovary measures 3.5 x 1.9 x 2.5 cm, containing a 1.4 x 1.4 x 1.4 cm complex cyst.
There are no adnexal masses. There is a small amount of free pelvic fluid.
Findings compatible with a missed abortion.