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 ICD-10-CM code Z85.47 is for a personal history of malignant neoplasm of testis. The CPT code 74178 is for a CT scan of the abdomen and pelvis with both intravenous and oral contrast, which matches the technique described.