Radiology Coding Alert

Deciding when you may report Doppler with ultrasound has been the talk around radiology-practice water coolers lately. Fortunately, our experts are here to clear up the confusion with a look at the available guidelines and how to apply them to your claims.

Last month, "Don't Let Poor Paperwork Steal $514 From Your Doppler Claims" covered the ordering guidelines for Doppler and ultrasound. This month, you'll discover the guidelines for adequate documentation, using the same real-life report as last month to reveal what you should and shouldn't do. (Note: Turn to page 83 to review the sample report.)

The sample report indicates both transvaginal (TV) and transabdominal (TA) ultrasound (US), says Raymond E. Bertino, MD, FACR, FSRU, vascular and general ultrasound director for OSF Saint Francis Medical Center, radiology and surgery clinical professor at University of Illinois College of Medicine at Peoria.

The sample's original order is for TV US only. Assuming you meet the order requirements discussed last month, the report still needs to offer adequate documentation to support coding both TV and TA US (Radiology Coding Alert, Vol. 10, No. 10, page 73).

Needs improvement: Whether the pelvic TA study was complete or limited is unclear in the sample report, says Bertino.

What to look for: CPT guidelines for 76856 (Ultrasound, pelvic [nonobstetric], real time with image documentation; complete) state that a complete female nonobstetric pelvic US "includes the complete evaluation of the female pelvic anatomy. Elements of this examination include a description and measurement of the uterus and adnexal structures, measurement of the endometrium, measurement of the bladder (when applicable), and a description of any pelvic pathology (e.g., ovarian cysts, uterine leiomyomata, free pelvic fluid)."

If your radiologist does not include this information, you will be limited to 76857 (Ultrasound, pelvic [nonobstetric], real time with image documentation; limited or follow-up [e.g., for follicles]), which brings in an average of $18 less from Medicare.

Another problem: The documentation also does not explain why the patient required both TV and TA exams, says radiology coding expert Jackie Miller, RHIA, CPC, senior coding consultant for Coding Strategies Inc. in Powder Springs, Ga.

Solution: You should have at least a separate paragraph stating the second exam's medical necessity and any salient findings, Miller explains.

Tip: The provider might point to the ovarian cyst and the cancer tests recommended in the impressions as a rationale for the added tests, but the report needs to state the medical necessity for the tests explicitly, Miller says.

The report also documents Doppler, Bertino notes.

Snag: CPT 2008 added the requirement that you must perform both color and spectral Doppler to report a Doppler exam. In the Diagnostic Ultrasound guidelines, CPT also states you may not report color Doppler performed for anatomic structure identification with a real-time ultrasound.

The sample report does not document both modalities (color and spectral), Bertino says.

Caution: Suppose the radiologist specified both color and spectral Doppler. You'd still have a hard time defending even a limited duplex (93976, Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study) if the radiologist mentions only "Doppler evaluation demonstrates a resistive index of 0.3 suggestive of low resistive blood flow," as the sample exam does, Miller says.

Better: The radiologist should dictate a separate paragraph for the duplex if she wants to bill it, says Miller. You need enough information to justify appending modifier 59 (Distinct procedural service) on the US code, she says. Otherwise the payer will bundle the US into the duplex.

For example, Bertino suggests the following template:

• Transabdominal imaging showed ...

• Transvaginal imaging showed...

• Color and spectral Doppler showed...

Bottom line: The sample report supports coding only TV US, 76830 (Ultrasound, transvaginal), not TA US or Doppler.

Your claim won't be complete without the appropriate ICD-9 codes to support medical necessity.

Submit 620.2 (Unspecified noninflammatory disorder of ovary, fallopian tube and broad ligament) for the ovarian cyst and 218.9 (Leiomyoma of uterus, unspecified) for the fibroids.