BC3020 Week 3 Coding Application

RADIOLOGY REPORT

LOCATION: Hospital, Outpatient

PATIENT: Dan Diel

ORDERING PHYSICIAN: Daniel G. Olanka, MD

ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD

RADIOLOGIST: Morton Monson, MD

PERSONAL PHYSICIAN: Ronald Green, MD

EXAMINATION: Gallbladder ultrasound.

CLINICAL SYMPTOMS: Increased bilirubin.

GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.

IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.

Identify the correct diagnosis (ICD-9-CM) code(s) for the above scenario?

ICD-9-CM: __________

re: BC3020 Week 3 Coding Application

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