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Code This!

Scenario Week of June 28, 2013:
View Current Scenario

Assign the Correct ICD-9-CM Diagnosis and CPT Diagnosis and Procedure Codes for the Following Coding Scenario.

A 24-year-old patient complaining of abdominal pain is seen in the radiology department of the hospital for a transvaginal ultrasound examination.

Exam: Transvaginal ultrasound

History: Pelvic pain

Findings: The right ovary measures 1.7 x 3.6 x 2.0 cm. There are several simple-appearing cysts, probably follicular. There is no indication of torsion on the right. Left ovary is enlarged, at 6.3 x 3.1 x 4.3 cm, with a complex cystic mass of unknown etiology. The left ovary is a possible large hemorrhagic cyst versus abscess. There is no indication of left ovarian torsion. There is a small amount of fluid in the cul-de-sac.

The uterus measures 7.8 x 5.2 cm. The endometrial echo is normal at 6 mm.


  1. No indication of torsion.
  2. Large, complex cystic left ovarian mass, possibly a large hemorrhagic cyst; however, an abscess/neoplasm cannot be excluded. Recommend either short interval follow-up versus laparoscopic evaluation given the large size and complex nature.

Assign the appropriate ICD-9-CM and CPT diagnosis and procedure codes.

Coding Answers

76830 Ultrasound, transvaginal

Code 76830 is reported because the documentation indicates that the ultrasound was performed transvaginally and contains a detailed description, including the size of the uterus and adnexal structures and endometria.

V72.5 Radiologic examination, not elsewhere classified
620.2 Other and unspecified ovarian cyst
620.0 Follicular cyst of the ovary

Since the reason for the visit is for the radiologic examination, code V72.5 is reported. This can be found using the main term “Admission,” subterms “examination, radiological NEC” in the ICD-9-CM alphabetic index.

The radiology report indicates a cystic mass of the left ovary. Using the main term “Cystic,” we are instructed to see the main term “Cyst.” The main term “Cyst,” subterms “ovary, ovarian (twisted)” and “unspecified,” refer to code 620.2. Notes in the tabular index indicate that this code is used to report cysts, which are not otherwise specified. Since a more definitive diagnosis cannot be determined without further testing, this is the correct code to report.

Code 620.0 is also reported since the ultrasound revealed follicular cysts of the right ovary. This code is located using the main term “Cyst,” subterms “ovary” and “follicular (atretic) (graafian) (hemorrhagic).”

Because of the findings of the follicular cyst on the right and the cystic mass on the left, which are likely responsible for the patient’s pain, the symptom of pelvic pain should not be reported.

CPT is a registered trademark of the American Medical Association. CPT only © 2012 American Medical Association.

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