Part B Insider (Multispecialty) Coding Alert

Question: Which ultrasound code applies for examining a mass on the back?

Answer: The answer depends on whether the physician documents the mass as being on the upper back, the lower back, or focused on the spinal canal.

CPT® Assistant (May 2009) supports the following coding for ultrasound of a palpable soft-tissue mass:

• Upper back: 76604, Ultrasound, chest (includes mediastinum), real time with image documentation
• Lower back: 76705, Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant, follow-up).

Spinal canal: Alternatively, if the mass is not suspected of being in soft tissue and the documentation shows ultrasound of the spinal canal, you should report 76800 (Ultrasound, spinal canal and contents). Remember that "It is inappropriate to report this code for each area of the spine. From a CPT® coding perspective, code 76800 includes the entire spinal canal," according to CPT® Assistant (April 1998).