By Senthil Kumar Eithirajan , B.Pharm, CPC
All diagnostic ultrasound examinations require permanently recorded images with measurements are clinically indicated.
For those anatomic regions that have complete and limited codes, note the elements that comprise a complete exam.
The report should contain a description of these elements or the reason that the element could not be visualized (e.g. obscures by bowel gas, surgically absent).
A Complete ultrasound examination of the abdomen (76700) consist of real time scans of
A Complete Ultrasound examination of the retroperitoneum(76770) consist of real tome scans of Kidneys, Abdominal Aorta, Common iliac artery origins, IVC Including any demonstrated retroperitoneal abnormality.
Alternatively, if clinical History suggest Urinary tract pathology, complete evaluation of kidneys and urinary bladder also comprises a complete retroperitoneal ultrasound.
Ultrasound-when to down code
There are strict criteria for what constitutes a complete abdominal ultrasound or renal ultrasound, and each organ or structure must be documented in the medical report to justify the "complete" code. If any anatomical structure is missing, you must down-code to a limited study.
Code 76856 includes the complete evaluation of female pelvic anatomy. Elements of this examination include a description and measurements of the uterus and adnexal structures, measurement of endometrium, measurement of the bladder(when applicable) and description of any pelvic pathology(eg ovarian cyst, uterine lyomyomata, free pelvic fluid)
Code 76856 is also applicable to a complete evaluation of male pelvis. Elements of examination include evaluation and measurement(when applicable) of the bladder, evaluation of prostate and seminal vesicles to the extent that they are visualized transabdominally, and any pelvic pathology(eg bladder, tumor, enlarges prostate, free fluid, pelvic abscess)
Codes 76801 & 76802 include determination of :
The number of gestation sacs and fetuses
Gestational sac/fetal measurements appropriate for gestation(younger than 14 weeks 0 days)
Survey of visible fetal and placental anatomic structure
Qualitative assessment of amniotic fluid/gestational sac shape and examination of the maternal uterus and adnexa
Codes 76805 and 76810 include determination of:
The number of fetuses and amniotic/chorionic sacs
Measurements appropriate for gestational age(older than or equal to 14 weeks 0 days),
Survey of intracranial/spinal abdominal anatomy, 4 chambered heart
Umbilical cord insertion site
Placenta location and amniotic fluid assessment
When visible, examination of maternal adnexa.
Codes 76811 and 76812 include all elements of codes 76805 and 76810 plus detailed anatomic evaluation of fetal brain/ventricles, face, heart/outflow tracts and chest anatomy, number/length/architecture of limbs and detailed evaluation of umbilical cord and placenta and other fetal anatomy as clinically indicated.
Code 76815 represents a focuses “Quick look” exam limited to the assessment of one or more of the elements listed in the code 76815.
76816 describes an examination designed to reassess fetal size and interval growth or reevaluate one or more anatomic abnormalities of few previously demonstrated on ultrasound, and should be coded once for each fetus requiring reevaluation
Code 76817 describes transvaginal Obstetric ultrasound performed separately or in addition to one of the transabdominal examinations described above. For transvaginal examinations performed for Non Obstetrical purposes use 76830
Evaluation of Vascular structures using both color Doppler and spectral Doppler is separately reportable To report see Non invasive Vascular Diagnostic studies (93922-93990)
Non invasive Vascular Diagnostic Studies
Duplex scan describes an ultrasonic scanning procedure for characterizing the pattern and direction of blood flow in arteries and veins with the production of real time images integrating B-mode 2 dimensional vascular structure, Doppler spectral analysis and color flow Doppler imaging.
Bedside ultrasound may be used in support of another procedure. For instance, ultrasound guidance is frequently used for needle placement and vascular access. Ultrasound guidance used for needle placement for procedures, such as needle biopsy or aspiration or injections, would be reported with CPT® 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation. The ultrasound is used to aid localization with a needle.
Ultrasound guidance for central venous line placement would be reported with +76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure). Ultrasound guidance codes should be reported in addition to the primary procedure. For example, a provider uses ultrasound guidance to place a subclavian central venous line. The central line would be reported 36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older, with +76937.
Evaluation of an extremity (i.e., arm including axilla or leg (non-vascular)) would be reported with 76882 Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific.
Evaluation of soft tissue of the neck would be reported with 76536 Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation.
Chest wall and upper back would be reported with 76604 Ultrasound, chest (includes mediastinum), real time with image documentation.
Lower back and abdominal wall would be reported with 76705.
Non invasive Vascular Diagnostic Studies
Non invasive physiologic studies are performed using equipment separate and distinct from duplex scanner. Codes 93922, 93923 and 93924 describe the evaluation of non-imaging physiological recordings of pressures, Doppler analysis of Bi Directional flow, Plethysmography and or oxygen tension measurements appropriate for anatomical area studied.
93880—Duplex scan of extracranial arteries, Complete bilateral arteries
93882 --Duplex scan of extracranial arteries, Unilateral or limited studies
93975—Duplex scan arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and /or retro peritoneal organs; complete study
93976--Duplex scan arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and /or retro peritoneal organs; limited study