Radiology Coding Alert

Master 'complete' and 'limited' to end this costly mistake

If you’ve ever faced the question of whether you can report a duplex scan and ultrasound together, you’re in luck. Our experts reveal what you need to know to code limited and complete visceral and penile vascular studies.

The procedure: A duplex scan is a noninvasive vascular diagnostic study--an ultrasonic scanning procedure display of the following:

• the two-dimensional structure of the target analysis and the vessels’ motion with time
• the Doppler ultrasonic signal of the flowing blood.

You need full documentation of these anatomic and physiologic parameters to report these codes.

The documentation should also include a spectrum analysis and/or color flow mapping or imaging of the flowing blood, says Cynthia A. Swanson, RN, CPC, senior consultant for Seim, Johnson, Sestak & Quist LLP, in Omaha, Neb.

The duplex scan codes specific to visceral and penile vascular studies are in the 90000 section of the CPT manual, says Stacie L. Buck, RHIA, LHRM, vice president of Southeast Radiology Management:

• 93975--Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study

• 93976--… limited study

• 93978--Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study

• 93979--… unilateral or limited study

• 93980--Duplex scan of arterial inflow and venous outflow of penile vessels; complete study

• 93981--… follow-up or limited study. Cut Out Missed Opportunities to Code ‘Complete’ You should assign a “limited” code, such as 93976, when the documentation describes imaging only a portion of the code descriptor’s components.

Example: The radiologist imaged the blood flow of only a specific portion of a single abdominal organ. Report 93976.

The beginning of the descriptor for 93975 and 93976 states “and/or,” so you don’t have to report a limited code just because the physician didn’t study all of the anatomic areas in the descriptor. A complete abdominal study, without mention of the other anatomic areas, may still merit complete code 93975.

But for the “complete” procedure, you must see evaluation of all major vessels supplying blood flow (inflow and outflow, with or without color flow mapping) to the target organ, Buck says.

Note: You don’t have to choose a limited code if despite best efforts (described in detail in the imaging report) the physician can’t visualize the target vessels, perhaps because [...]