Assign the ICD-10-CM code(s) to diagnoses and conditions and assign the CPT medicine code(s) and the appropriate HCPCS level II and CPT modifier(s). Do not assign ICD-10-CM external cause codes.
1. CAROTID ULTRASOUND
DIAGNOSIS: Screening exam, risk factors for cardiovascular disease.
Multiple real-time images were made of both carotid arteries from the supraclavicular area to the bifurcation.
The common carotid arteries are of normal caliber bilaterally with no evidence of any plaque formation or
stenosis. The bifurcations are well demonstrated bilaterally and are normal. There is a very tiny calcified
plaque involving the posterior wall of the left carotid artery just proximal to the bifurcation. This is only
about 2 mm in size, and I do not think it is significant.
CONCLUSION: Normal carotid ultrasound.