Question: The provider performs a complete abdominal ultrasound on a patient with chronic abdominal pain. In the findings, I find documentation of the liver, gallbladder, bile duct, kidneys, and pancreas. The provider documents all four quadrants on the exam. Is this enough to code as 76700?
Oklahoma Subscriber
Answer: Appropriate documentation of 76700 (Ultrasound, abdominal, real time with image documentation; complete) requires more than just the physician documenting each of the four abdominal quadrants. According to CPT®, code 76700 requires the physician to document the following organs on the ultrasound:
Based on your description, your provider's documentation is missing the spleen, upper abdominal aorta, and inferior vena cava. Unless your provider can amend the report to include documentation of these three additional components, you will have to code this procedure as 76705 (Ultrasound, abdominal, real time with image documentation; limited [eg, single organ, quadrant, follow-up]).
Even if the provider clearly documents each of the four abdominal quadrants, that alone is not enough to warrant the use of code 76700. On the other hand, the only requirements for code 76705 are documentation of a single organ or single abdominal quadrant. Since, in this example, the provider's intentions were presumably to meet the standards applied for 76700, you should send this claim back to see if the provider can clarify/amend the dictation report.
