# 76770 vs 76775



## chembree (Nov 14, 2011)

Does anyone have any documentation or guidance on what constitutes a complete retroperitoneal ultrasound?

I know a complete includes documentation of the following structures: (Kidneys, Abdominal Aorta, Common Iliac Artery origins, and the Inferior Vena Cava) 

But what confuses me is that alternatively, if the patient is being examined for urinary tract problems a complete exam can consist of the following: (Kidneys and urinary bladder)… So what is included as acceptable urinary tact pathology?  Would any form of pathology from any part of the urinary tract be sufficient… such as the kidneys? Or does the diagnosis need to be a true urinary diagnosis? 

Also, since CPT says if the clinical history suggests urinary tract pathology it is complete… does this mean it can only be supported by the history and not the final diagnosis? 

I appreciate any help or guidance about this!


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## donnajrichmond (Nov 14, 2011)

if the reason for the exam is anything to with urinary tract (kidneys, ureter, bladder), then bilateral kidneys and bladder is a complete study.  This can be hydronephrosis, kidney stone, post-void residual, etc.  If it is something like pain, the physician would need to link it to urinary tract such as "right upper quadrant pain, r/o kidney stone".
If the reason for the exam is not urinary tract (such as looking for AAA), then a complete study requires Kidneys, Abdominal Aorta, Common Iliac Artery origins, and the Inferior Vena Cava even if an incidental finding is made in the urinary tract.  
CPT instructions say that "clinical history" determines whether kidneys and bladder is a complete or limited.


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