CT Scan of the Abdomen and Pelvis
History: Malignant testicular neoplasm
Technique: Axial CT images of the abdomen and pelvis were obtained with intravenous and oral contrast.
Findings: Images of the lung bases are normal. Images of the abdomen show the liver, spleen, gallbladder, pancreas, and adrenal glands to be normal. No mass is seen. There is no evidence of cholelithiasis. A retroaortic left renal vein is seen. No obvious mass or enlarged lymph nodes are noted in the retroperitoneum. Mesenteric structures appear normal. A prominent inferior vena cava is seen. Gas is identified in the left inguinal structures, likely representing previous left orchidectomy and removal of the inguinal ring. No enlarged lymph node is identified in the pelvis.
Impression: Left retroaortic renal vein is seen. No adenopathy is noted within the abdomen or pelvis. No enlarged lymph node is seen; no mass is identified.
Select the appropriate ICD-10-CM and CPT code(s):

Question

Quizplus · Accepted Answer

The correct ICD-10-CM code is Z85.47, which is for a personal history of malignant neoplasm of testis, matching the patient's history of malignant testicular neoplasm. The correct CPT code is 74178, which is for a CT scan of the abdomen and pelvis with contrast, as indicated by the technique section stating that the images were obtained with intravenous and oral contrast.