coding challenge

Coding Challenge 7

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

#1111222222


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

Impression:

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.

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