ICD 10 Coding Alert

Question: A patient recently underwent a right kidney transplant. I have a report for a complete ultrasound (US) exam of the patient’s kidneys and retroperitoneal structures. The report includes documentation of the patient’s abdominal aorta, common iliac artery origins, inferior vena cava, and kidneys. The radiologist noted a 5.6 x 3.0 cm right transplanted kidney with a probable 8 mm cyst present, as well as an 8.7 x 4.1 cm left native kidney with a probable 9 mm cyst present. The indication for the scan is a follow-up examination after the transplant.

What codes will I need to report this encounter?

Codify Subscriber

Answer: Starting with the procedure code, you’ll assign 76770 (Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete) to report the complete retroperitoneal US. Some coders may be tempted to assign 76776 (Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation) and 76775 (… limited) to report the US exam of the transplanted kidney and a limited US of the rest of the retroperitoneum, but that is incorrect.

According to the 2023 National Correct Coding Initiative Policy Manual for Medicare Services, Chapter IX, Section C.13, “Ultrasound examination of a transplanted kidney and retroperitoneal structures at the same patient encounter may be reported with CPT^® code 76770. It shall not be reported with CPT^® code 76776 plus CPT^® code 76775.”

Next, you’ll turn to the ICD-10-CM code set to report the diagnosis codes. Since the radiologist is performing the US as part of follow-up care after the kidney transplant, you’ll need to assign an aftercare code. To locate the correct code, search the indentations in the Alphabetic Index to follow Aftercare > following surgery (for) > organ transplant > kidney. You’ll then verify Z48.22 (Encounter for aftercare following kidney transplant) in the Tabular List.

You’ll also assign Z94.0 (Kidney transplant status) to indicate that the provider saw the patient because the patient recently received a kidney transplant. According to the ICD-10-CM Official Guidelines, section I.C.21.c.3, “Status codes indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition.” This includes transplanted organ or tissue status since the status code is informative and can affect the patient’s treatment.