Scenario 1
REASON FOR EXAM
Follow-up for fetal growth.
PRIMARY PROCEDURE
ULTRASOUND OB, FOLLOW-UP FOR FETAL GROWTH.
PROCEDURE
Real-time exam demonstrates a single intrauterine fetus in cephalic presentation with a regular cardiac rate of 147 beats per minute. The head to abdomen circumference ratio is normal at 1.08, and the femur length to abdomen circumference ratio is normal at 23.0%. The estimated fetal weight is 2001 gm. The amniotic fluid volume appears normal, and the calculated index is normal for age at 13.7 cm. A detailed fetal anatomic exam was not performed in this setting, as this was a limited exam for growth only. The placenta is posterofundal and grade 2.
DATABASE
FETAL BIOMETRY: BPD = 8.3 cm, 33 weeks, 4 days HC = 30.2 cm, 33 weeks, 4 days AC = 27.9 cm, 32 weeks, 0 days FL = 6.4 cm, 33 weeks, 1 day
IMPRESSION
Single, viable intrauterine pregnancy in cephalic presentation with a composite gestational age of 32 weeks, 5 days, plus or minus 17 days, giving an estimated date of confinement of 8/04/XX. There has been normal progression of fetal growth compared to the 2 prior exams of 2/11/XX and 4/04/XX. The examination of 4/04/XX questioned an echogenic focus within the left ventricle. The current exam does not demonstrate any significant, persistent echogenic focus involving the left ventricle.
Worth 2.000 points.
ICD-10 -
PCS code