LOCATION: Hospital, Outpatient
ORDERING PHYSICIAN: Daniel G. Orange, MD
ATTENDING/ADMIT PHYSICIAN: Daniel Orange, MD
RADIOLOGIST: Morton Manson, MD
PERSONAL PHYSICIAN: Ronald McDonald, MD
EXAMINATION: Gallbladder ultrasound.
CLINICAL SYMPTOMS: Increased bilirubin.
GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.
IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.
Identify the correct CPT-4 procedure (ICPT) code(s) for the above scenario?
CPT-4: _________ Modifier: __________
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