Forum - Questions & Answers

Sep 28th, 2015 - Aprilz0705

Vesicoureteral reflux

I'm new to radiology coding and had a question regarding a follow up exam.
My report says:
Procedure: US Renal
History: 22 month old female with history of vesicoureteral reflux on the RT, followup exam. History of surgical repair.
Impression: bilateral kidneys within normal limits. Right adnexal homogeneous echogenic mass.

My question is how to list the diagnosis codes. Should I use follow up exam as my primary diagnosis(V67.09) followed by history code (v13.09)? Furthermore, should I add the incidental finding of the mass (625.8)?
Thank you,
April Atkins, CPC

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