Neurology & Pain Management Coding Alert

Question: Encounter notes indicate that the provider ordered an ultrasound (US) on a patient’s right leg. The notes state that “US was comprehensive, went entire anatomic course.” How do I report this encounter?

Louisiana Subscriber

Answer: You’ll be using a code that’s new for 2023 for this encounter. On your claim, report 76883 (Ultrasound, nerve(s) and accompanying structures throughout their entire anatomic course in one extremity, comprehensive, including real-time cine imaging with image documentation, per extremity). Also, append modifier RT (Right side) to 76883 to indicate the laterality of the US.

During a 76883 encounter, the provider applies gel to the extremity, then uses a transducer to produce sound waves that bounce off body tissues and make echoes … “the transducer receives the echoes and sends them to a computer that uses them to create an image. The provider places the transducer head on the skin of the target area, imaging one or more nerves and the accompanying structures through their entire anatomic course in one extremity. This is a comprehensive exam,” according to Codify by AAPC.

“The image appears in real time on a monitor with cine (movie) imaging, and a permanent copy is made and documented in the medical record,” per Codify.