Location: Regional hospital. (Provided at the hospital, the radiologist will report the professional component.) Study: Ultrasound Urinary Tract
Indications: Status ureteral reimplantation (The surgical procedure has been performed. The ultrasound is being performed after a surgical procedure for evaluation of continued reflux.) to evaluate for continued vesicoureteral reflux.
Left Kidney:(Kidney evaluated.)
Length: 7.0 cm
Prior length: 7.4 cm
Parenchyma: Cortical scarring.
Pelvic dilatation: Normal
Calyceal dilatation: Normal
Hydronephrosis grade: Normal
Interval hydronephrosis change: None
Right Kidney:
Length: 6.6 cm
Prior length: 6.4 cm
Parenchyma: Cortical scarring.
Pelvic dilatation: Normal
Calyceal dilatation: Normal
Hydronephrosis grade: Normal
Interval hydronephrosis change: None
Ureters: (Ureters evaluated.) Normal
Bladder: (Bladder evaluated.) Almost empty and difficult to evaluate.
Impression:
1, Interval right renal enlargement without hydronephrosis. (Diagnosis—right renal growth.)
2. Stable asymmetric small left renal size (Additional diagnosis—small left renal size.) likely to represent diffuse cortical scarring.
What are the CPT® and ICD-10-CM codes reported for this service?