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Oncology & Hematology Coding Alert

Reader Question:

Stop Limiting Pelvic US Payments

Published on Thu May 01, 2003

Question: Our physician performed a nonobstetric ultrasound of the pelvic region on a Medicare patient for the sole purpose of treating the patient for unilateral ovarian disease. I reported 76856 (Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete), but my colleague thinks this selection is incorrect. Will you help us?

Virginia Subscriber

Answer: Your colleague is correct: Code 76856 is not the right selection for your physician's ultrasound. You should instead report 76857 (... limited or follow-up [e.g., for follicles]). A US study is limited if it includes a single diagnostic problem, as in your case, or a simple quadrant. A complete study, on the other hand, visualizes all of the pelvic structures (those generally within the pelvic rim and below the umbilicus) and includes a written interpretation, according to the local medical review policy from TrailBlazer Health Enterprises in Virginia. This LMRP reflects the stance taken by many LMRPs on various ultrasound sites.

Medicare in Virginia and many Medicare carriers should cover your physician's US because it's medically necessary when used in the treatment of disorders of the anatomical pelvis. You should report pelvic ultrasounds when:

  • they are medically necessary in the diagnosis and treatment of disorders of the anatomical pelvis
  • they evaluate pelvic symptoms or abnormal findings
  • they evaluate a patient with genital cancer
  • they evaluate a patient with a condition that makes a biannual pelvic examination inadequate for evaluating the pelvis
  • they evaluate a patient in pelvic pain to determine the diagnosis when standard abdominal, pelvic and rectal exams have failed to reveal the source of the problem.

    Virginia's and other LMRPs will not cover pelvic US CPT codes and finds them not medically necessary when:

  • practices routinely use them on all patients with pelvic pain. (You must have documentation in the patient's record noting the medical necessity of the routine US.)
  • the physician uses a handheld US device to determine postvoid residual bladder volume. For this service, report instead 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging).

    Go to this Web site to find the ICD-9 codes that support medical necessity in Virginia for these US codes: http://www.asco.org/ac/1,1003,_12-002393-00_18-0017544,00.asp?state=VA.

     

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