Radiology Coding Alert

Distinguish ultrasound and duplex vascular scan.

With so many potential uses of a renal ultrasound, coding the procedure makes an inevitable challenge. Here is more about coding of renal ultrasound to help you earn for this common frequent procedure.

What happens: Physicians use renal ultrasounds to assess the size, shape, and location of a patient’s kidneys and to assess pathological processes that may involve the kidneys. Ultrasound can help the physician determine needle placement for biopsies or tubes for drainage. Ultrasounds can detect renal cysts, calculi, tumors, abscesses, obstruction, fluid collection, and infection within or around the kidneys.

Ultrasound vs sonogram: In the document, your physician may mention ‘ultrasound’ or ‘sonogram.’ The terms ‘ultrasound’ and ‘sonogram’ are used interchangeably and reference the same exam, but don’t mean exactly the same thing.

An ultrasound uses high-frequency sound waves to scan an anatomic area and create a picture (sonogram) of the structures. In short, the ultrasound is the procedure used to produce a sonogram, which is the actual image.

Document All the Details

One of the first steps in coding ultrasounds is to verify whether the test was limited or complete. According to CPT^® guidelines, “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.” For a renal ultrasound, you should report 76775 (Ultrasound, retroperitoneal [e.g., renal, aorta, nodes], real time with image documentation; limited).

Other info: The more details the physician can include in his documentation, the more successful your coding will be. Items that should be included when documenting renal sonograms are:

• Evaluation of the upper, mid, and lower poles of each kidney in sagittal and transverse views
• Sagittal view to evaluate the cortex and renal sinus
• Renal length measurements of both kidneys
• Comparison of echogenicity of the kidney with adjacent structures (liver and spleen)
• Documentation of any abnormalities seen
• Renal parenchyma measurement, if indicated.

The first sentence in the CPT^® diagnostic ultrasounds section reads, “All diagnostic ultrasound examinations require permanently recorded images with measurements, when such measurements are clinically indicated.” For the majority of ultrasound studies, failure to have the image archived and retrievable would fail to meet the first requirement for the code.

Remember the Doppler Difference

Sometimes your physician will choose to perform a Doppler ultrasound, also known as a duplex study. A Doppler ultrasound allows the physician to assess renal arterial and venous patency and check for suspected conditions such as renal artery stenosis.

Correct coding for Doppler/duplex vascular study of the kidneys includes reporting:

• 93976 – Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study
• 76775 – Ultrasound, retroperitoneal [e.g., renal, aorta, nodes], real time with image documentation; limited.

Remember: Append modifier 59 (Distinct procedural service) to 76775 on your claim to differentiate the ultrasound test from the imaging Duplex scan. CPT^® code 76775 is bundled into code 93976, but may be unbundled and paid with the above modifier, so long as you have supporting documentation.

Know When Complete Retroperitoneal US Applies

Before finalizing your claim, remember one more important clinical and coding point for Medicare and other insurers.

“According to CPT^® (Current Procedure Terminology), CMS (Medicare), and the American College of Radiology (ACR), for patients with a clinical history suggesting urinary tract pathology, sonographic evaluation of both the kidneys and urinary bladder at the same encounter should be coded as a complete retroperitoneal ultrasound,” said Michael A. Ferragamo, MD, FACS, clinical assistant professor at the State University of New York at Stony Brook.

Therefore, the correct code to report would be 76770 (Ultrasound, retroperitoneal [e.g., renal, aorta, nodes], real time with image documentation; complete).

Take note: Many payers (but not all) as well as Medicare will not pay for both renal (76775) and bladder (76857, Ultrasound, pelvic [nonobstetric], real time with image documentation; limited or follow-up [e.g., for follicles]) sonograms reported at the same time. ICD-10 diagnostic coding can include kidney or bladder pathological diagnoses.

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

Don’t Miss the Diagnosis

Associated diagnoses might include any of the following:

• N28.0 – Ischemia and infarction of kidney
• I70.1 – Atherosclerosis of renal artery
• I77.0 – Arteriovenous fistula, acquired
• Q27.1 – Congenital renal artery stenosis
• Q27.2 – Other congenital malformation of renal artery
• Q27.4 – Congenital phlebectasia
• S37.061A – Major laceration of right kidney, initial encounter
• S37.062A – Major laceration of left kidney, initial encounter

Take note: Insurers rarely pay for renal Doppler ultrasound without specific documentation with the above diagnostic ICD-10 codes.