Oncology & Hematology Coding Alert

Learn when to report ‘complete’ vs ‘limited’ evaluation.

The extent of the evaluation your oncologist does during the ultrasound evaluation of the urinary tract guides you to the right code you should report. Take advice from experts for how to report ‘complete’ and ‘limited’ ultrasound evaluation of the urinary tract, a simple, non-invasive investigation that can help guide any further needed diagnostic planning to get to the final diagnosis and formulate a treatment plan.

Capture Complete US for Just Kidney and Bladder

Before choosing an ultrasound code for imaging of urinary structures, be sure to read the CPT^® guidelines. You may be surprised by which codes apply to the different studies.

For patients with a clinical history suggesting urinary tract pathology, complete evaluation of the kidneys and urinary bladder supports coding a complete retroperitoneal ultrasound, said Michael A. Ferragamo, MD, FACS, clinical assistant professor at the State University of New York at Stony Brook, in a recent presentation for AudioEducator.com.

You’ll find this rule for complete ultrasound for kidney and bladder evaluation in the CPT^® guidelines. The proper code is 76770 (Ultrasound, retroperitoneal [e.g., renal, aorta, nodes], real time with image documentation; complete).

This urinary tract pathology exception is important because CPT^® guidelines state 76770 would require ‘real time scans of the kidneys, abdominal aorta, common iliac artery origins, and inferior vena cava, including any demonstrated retroperitoneal abnormality.’

Do Not Skip the Diagnosis

When reporting the ultrasound examination, you should also report the appropriate diagnosis code. Diagnoses that may support a clinical history of urinary tract pathology include (but aren’t limited to) the following:

• Dysuria and painful urination (ICD-9: 788.1, Dysuria; ICD-10: R30.0, Dysuria; R30.9, Painful micturition, unspecified)
• Frequent urination and polyuria (ICD-9: 788.4x, Frequency of urination and polyuria; ICD-10, R35.-, Polyuria)
• Flank pain (ICD-9: 789.0x, Abdominal pain; ICD-10: R10.-, Abdominal and pelvic pain).

Keep Complete/Limited in Mind for Kidneys

Having established that coding guidelines allow you to report a complete retroperitoneal code 76770 for imaging of the kidneys and bladder in certain patients and for certain clinical scenarios raises the question of proper coding for ultrasound of only the kidneys or ultrasound of only the bladder. Let’s start with ultrasonic examination of only the kidneys.

CPT^® guidelines state, “If less than the required elements for a ‘complete’ exam are reported (e.g., limited number of organs or limited portion of region evaluated), the ‘limited’ code for that anatomic region should be used once per patient exam session.”

It would be logical for you to assume that if the complete retroperitoneal code applies to the kidneys and bladder, then the limited code applies to ultrasound of only the kidneys.

In the case of kidneys, your assumption is correct. Note the use of the term “renal” (kidney-related) in the definition of 76775 (Ultrasound, retroperitoneal [e.g., renal, aorta, nodes], real time with image documentation; limited). So, for ultrasound of the kidneys only, you should report 76775.

Look Beyond 76775 for Bladder Imaging

Although the limited retroperitoneal code is appropriate for ultrasound of the kidneys only, you should not use a retroperitoneal code for imaging of just the bladder anatomy, Ferragamo says.

Instead, you should use limited pelvic ultrasound code 76857 (Ultrasound, pelvic [nonobstetric], real time with image documentation; limited or follow-up [e.g., for follicles]). CPT^® guidelines state that “Code 76857, rather than 76770, should be utilized if the urinary bladder alone (i.e., not including the kidneys) is imaged.”

Tip: “Documentation of a bladder ultrasound should include measurements of the thickness of the bladder wall, the presence of any diverticula (small outpocketings through the bladder wall), any stones present within the diverticula, the bladder interior including presence of any tumors or stones, and for male patients demonstration of an enlarged prostate gland deforming the bladder floor and base,” Ferragamo says.