# Ultrasound Abdomen documentation - The Dr. wants to bill a complete



## jmizzer (Jan 25, 2013)

I have a question on the documentation in this report for a complete Abdominal U/S. The Dr. wants to bill a complete and I didn't agree with his description for the IVC and Aorta and would love some ideas. If anyone has anything in writing I can give him in black and white that would be great! He is stating the sentence " There is no evidence of aneurysm. Retroperitoneal Vasculature appears within normal limits that the "Retroperitoneal Vasculature" means the IVC and Aorta. A couple girls I work with and myself think this could be many structures in this area and not just the Aorta and IVC. Help please! 

Examination: US ABDOMEN
Exam Date: 01/18/2013

CLINICAL HISTORY: Thrombocytopenia and history of hepatic steatosis
evaluate for splenomegaly

Real time ultrasound examination was performed in order to evaluate the
liver, spleen, gall bladder, common bile duct, pancreas, kidneys, aorta and
inferior vena cava. Color Doppler and Spectral Waveform imaging was
performed in order to characterize the pattern and directional flow in the
arteries and veins and to assess for abnormal vascularity in regions of
interest, as requested.

The liver appears enlarged and increased in echogenicity, consistent with a
fatty liver. No discrete focal mass is identified. No bile duct dilation is
identified.

No gallstones are evident.

The CBD measures 5 mm which is within normal limits.

Imaging of the kidneys is unremarkable.

The spleen is enlarged measuring 18.5 cm. It appears homogeneous in
echotexture.

There is no evidence of aneurysm. Retroperitoneal vasculature appears
within normal limits.

Color Doppler and spectral waveform imaging of the upper abdomen show
patency of the vasculature. No flow related abnormality is detected.

IMPRESSION:

Splenomegaly

Increased size and increased echogenicity the liver. This is consistent
with hepatic steatosis.

No evidence of gallstones or bile duct dilation.


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## RADCODER (Jan 28, 2013)

I understand where you are coming from but if you separate the terms, the Dr does make sense. Take a look at the Retroperitoneal structure:

Structures that lie behind the peritoneum are termed "retroperitoneal". Organs that were once suspended within the abdominal cavity by mesentery but migrated posterior to the peritoneum during the course of embryogenesis to become retroperitoneal are considered to be secondarily retroperitoneal organs.

Primarily retroperitoneal: 




Urinary 
adrenal glands
kidneys
ureter
bladder




Circulatory 
aorta
inferior vena cava





Digestive 
esophagus (thoracic part, part inside abdominal cavity is intraperitoneal)
rectum (part, lower third is extraperitoneal)

Secondarily retroperitoneal: 
the head, neck, and body of the pancreas (but not the tail, which is located in the splenorenal ligament)
the duodenum, except for the proximal first segment, which is intraperitoneal
ascending and descending portions of the colon (but not the transverse colon or the cecum)

Then take a look at the term Vasculature:

Vasculature
1. circulatory system.
2. any part of the circulatory system.
3. the supply of vessels to a specific region.

To sum up I think it is just a fancier way of saying IVC/Aorta. As coders it is easier for us when we see the same terms over and over and then when Drs throw in alternative meanings it might get confusing. In my opinion I would say it is safe to use the term Retroperitoneal Vasculature when describing the IVC/Aorta (although I have never seen it used.)

Hope this helps!


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## donnajrichmond (Jan 28, 2013)

jmizzer said:


> I have a question on the documentation in this report for a complete Abdominal U/S. The Dr. wants to bill a complete and I didn't agree with his description for the IVC and Aorta and would love some ideas. If anyone has anything in writing I can give him in black and white that would be great! He is stating the sentence " There is no evidence of aneurysm. Retroperitoneal Vasculature appears within normal limits that the "Retroperitoneal Vasculature" means the IVC and Aorta. A couple girls I work with and myself think this could be many structures in this area and not just the Aorta and IVC. Help please!
> 
> Examination: US ABDOMEN
> Exam Date: 01/18/2013
> ...



I would NOT allow a complete.  CPT is quite clear about what must be documented for 76700.  Auditors, particularly government auditors are going to be looking for specific words as noted in CPT as well as multiple guidelines by ACR.  Upper abdominal aorta and IVC are specified as required for 76700.  Saying "retroperitoneal vasculature appears within normal limits" does not say he looked at all of the retroperitoneal vasculature - he could have looked just at the aorta, or just the iliac arteries, or just the IVC.


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## jmizzer (Jan 30, 2013)

Thank you Donna for your response and knowledge. It is greatly appreciated!!


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## tmlbwells (Jan 30, 2013)

Doesn't the fact that the aorta and ivc are discussed in the body of the report count for the complete ultrasound?


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