Please code the ICD-10-CM and CPT code for this report. To check your answers, click the link at the bottom of the report.
ABC Hospital
Patient Name- Jon Doe
Date- 1/1/18
Referring Dr- Dr Smith
Exam- US Renal
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Procedure- US Renal
History- Routine check of renal cysts
Technique-2D images
Findings- Complete evaluation of the right kidney. Right kidney is normal in size with no hydronephrosis. No calculus. Simple cyst measuring 1.4 x 2.1 x 3.6 located mid portion. Simple cyst #2 measuring 1.7x 1.9 x 1.6 located upper pole.
RT kidney retroperitoneal measurements- length 9.71 AP 5.04 cm. width 5.52 cm
Complete evaluation of the left kidney. The kidney is normal in size with no hydronephrosis. Complex cyst measuring 2.2x 1.2x 1.5 located mid portion. Visualized portion of the IVC are normal. Proximal and abdominal aorta obscured by bowel gas.
LT kidney retroperitoneal measurements- length 11.50 cm AP width 6.25 cam
The bladder is normal.
Prostate is normal.
Impression- No hydronephrosis. Bilateral renal cysts.
Signed by Dr Michaels 4:00 pm 1/1/18
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