Radiology Coding Alert

Question: Our physician did 3D translabial ultrasounds to review the pelvic floor and rectal muscles using still images and to watch for dynamic changes in the rectal wall, such as out-pouching or herniation. The transducer was placed on the body surface and neither the vagina nor the rectum was entered. Can we submit code 76376 or 76377 for this procedure?

Virginia Subscriber

Answer:

There is no CPT® code for the sonographic procedure described. For your clinical scenario, first report 76999 (Unlisted ultrasound procedure [e.g., diagnostic, interventional]) for the external study. Bench mark the unlisted procedure with 76856 (Ultrasound, pelvic [nonobstetric], real time with image documentation; complete).

You next report 76376 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic  modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation) for the 3D rendering.