Please code the CPT and ICD-10-CM code for this report. This report is HIPAA compliant and does not contain PHI.
Exam- Right hip including pelvis 2-3 views
Date- June 4, 2018
Exam-Hip x-ray right including pelvis 2-3 views
Clinical History- Right hip pain
Comparison- hip x ray 2/4/17
Technique- 2 views of the right hip and 1 ap view of the pelvis was performed
Findings: Pelvis ring intact. The sacroiliac joints are symmetric. No right hip fracture or dislocation. Punctate ossific density adjacent to the right hip. Left hip unremarkable.
Soft tissue- normal
No right hip fracture or dislocation. Punctate ossific density adjacent to the right hip most likely related to degenerative changes.
Thank you for referring your patient.