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Original Question
Patient Name: Barbara Hawley DOB: 07-19-67 Ordering Physician: Oliva Birch, MD Gender: F Interpreting Physician: Angela Powers, MD Date of Service: 12-12-XX Indication: Hydronephrosis Exam: Portable right retrograde pyelogram History: 52-year-old female with right hydronephrosis Comparison: none Technique: 6 portable intraoperative views utilizing C-arm apparatus. Findings: Select images from a right retrograde pyelogram were submitted for interpretation. Contrast is seen to fill the right pyelocaliceal systems and right ureter. There is a persistent filling defect within the proximal right ureter compatible with a right ureteral calculus with subsequent dilatation of the right renal pelvis. There also appears to be a persistent narrowing within the right ureter at the level of the pelvic inlet which may represent a ureteral stricture as there is subsequent dilatation of the right ureter proximal to this level. The last image obtained demonstrates the placement of a right ureteral stent which is in good position. Impression: Proximal right ureteral calculus with right hydronephrosis and a persistent narrowing within the right ureter at the level of the pelvic inlet may represent a stricture with subsequent hydroureter and hydronephrosis proximally with interval placement of a right ureteral stent. Give the correct CPT and ICD-10 codes.
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