Question: Should we report a limited or complete abdominal ultrasound when the dictation only mentions one of the patient’s two kidneys? The dictation meets every other requirement to be complete.
Texas Subscriber
Answer: If the radiologist only describes one kidney and fails to explain why he didn’t describe the other, you must report a limited exam (76705, Ultrasound, abdominal, B-scan and/or real time with image documentation; limited).
CPT guidelines for diagnostic ultrasounds state that to report a “complete” exam, the report should contain a description of all required elements or must explain why the element couldn’t be visualized.
Example: The radiologist documents that the organ is obscured by bowel gas or is surgically absent. A complete abdominal ultrasound “consists of B mode scans of the liver, gall bladder, common bile duct, pancreas, spleen, kidneys, and the upper abdominal aorta and inferior vena cava including any demonstrated abnormality.”
-- Reader Questions reviewed by Sarah L. Goodman, MBA, CPC-H, CCP, president of SLG Inc. in Raleigh, N.C.
