Case
-AUDIT REPORT T3.2 ULTRASOUND, RENAL
LOCATION: Outpatient, Hospital
PATIENT: Derrick Smith
PHYSICIAN: Ronald Green, MD
RADIOLOGIST: Morton Monson, MD
EXAMINATION OF: Renal ultrasound
CLINICAL SYMPTOMS: Anuria
RENAL ULTRASOUND: The right kidney measures 12.9 6.4 5.3 cm. The left measures 11.8 5.0 6.5 cm. There is no evidence for hydronephrosis within either of the kidneys. Focal density is seen within the midportion of the right kidney, which may relate only to a prominent column of Bertin; however, those do appear slightly different from the adjacent parenchyma and cannot exclude the possibility of mass in this area. Correlation with renal CT is recommended. There is a large cyst associated with the lower pole of the right kidney measuring 8.1 8.0 5.2 cm.Within the left kidney, there are two echogenic shadowing foci. One is within the upper pole measuring 4 mm and, in the lower pole, the second is seen measuring 3 mm to 4 mm. Both of these are compatible with small left renal calculi. Urinary bladder demonstrates an unremarkable sonographic appearance well distended. It demonstrates an approximately 66 cc post-void residual.
IMPRESSION:
1. Density noted within the midportion of the right kidney, which may relate only to a prominent column of Bertin; however, the possibility of underlying mass cannot be excluded. Renal CT is recommended.
2. Large lower pole acquired cyst involving the right kidney.
3. At least two left renal calculi are identified.
4. Post-void residual, as given.
T3.2:
SERVICE CODE(S): 76775____________________________________________
ICD-10-CM DX CODE(S): R34_________________________________________
INCORRECT/MISSING CODE(S): _____________________________________

Question

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The Answer of Case
-AUDIT REPORT T3.2 ULTRASOUND, RENAL
LOCATION: Outpatient, Hospital
PATIENT: Derrick Smith
PHYSICIAN: Ronald Green, MD
RADIOLOGIST: Morton Monson, MD
EXAMINATION OF: Renal ultrasound
CLINICAL SYMPTOMS: Anuria
RENAL ULTRASOUND: The right kidney measures 12.9 6.4 5.3 cm. The left measures 11.8 5.0 6.5 cm. There is no evidence for hydronephrosis within either of the kidneys. Focal density is seen within the midportion of the right kidney, which may relate only to a prominent column of Bertin; however, those do appear slightly different from the adjacent parenchyma and cannot exclude the possibility of mass in this area. Correlation with renal CT is recommended. There is a large cyst associated with the lower pole of the right kidney measuring 8.1 8.0 5.2 cm.Within the left kidney, there are two echogenic shadowing foci. One is within the upper pole measuring 4 mm and, in the lower pole, the second is seen measuring 3 mm to 4 mm. Both of these are compatible with small left renal calculi. Urinary bladder demonstrates an unremarkable sonographic appearance well distended. It demonstrates an approximately 66 cc post-void residual.
IMPRESSION:
1. Density noted within the midportion of the right kidney, which may relate only to a prominent column of Bertin; however, the possibility of underlying mass cannot be excluded. Renal CT is recommended.
2. Large lower pole acquired cyst involving the right kidney.
3. At least two left renal calculi are identified.
4. Post-void residual, as given.
T3.2:
SERVICE CODE(S): 76775____________________________________________
ICD-10-CM DX CODE(S): R34_________________________________________
INCORRECT/MISSING CODE(S): _____________________________________

Case -AUDIT REPORT T3.2 ULTRASOUND, RENAL