Radiology Coding Alert

Question: I am working on a ultrasound (US) abdomen complete with the findings documented as follows:

“The liver is homogeneous and exhibits normal echo texture. There is no focal hepatic abnormality. There is no intra or extrahepatic biliary dilatation. The extrahepatic duct is normal caliber at 3 mm. The gallbladder is normal, showing no evidence of wall thickening, choleli­thiasis, or pericholecystic fluid. Limited views of the spleen are normal. The head and body of the pancreas are normal. Renal cortical thickness and echogenicity are normal. The right kidney measures 11.0 cm and the left kidney measures 2.4 cm. There is no free fluid. The visualized abdominal vasculature is normal. Inferior vena cava where seen is normal caliber.”

The physician only documents the extrahepatic and intrahepatic biliary ducts. Is that enough to conclude that the physician also examined the common bile duct?

Oregon Subscriber

Answer: In order to bill out for 76700 (Ultrasound, abdominal, real time with image documentation; complete), the physician must document the following anatomical sites:

• Liver,
• Gallbladder,
• Common bile duct,
• Pancreas,
• Kidneys,
• Spleen,
• Upper abdominal aorta, and
• Inferior vena cava.

Since the common bile duct is anatomically interrelated between the extrahepatic and intrahepatic bile ducts, an examination of the two is sufficient documentation to check the common bile duct off your list. However, what’s not included in this list is the upper abdominal aorta. Without documentation supporting its visualization (or lack thereof), billing for 76700 is not warranted.

In its current state, the documentation only supports code 76705 (Ultrasound, abdominal, real time with image documentation; limited [eg, single organ, quadrant, follow-up]).

Billing out for 76705, however, isn’t recommended in this case. If the physician labels the exam title as a complete exam, and the documented anatomical sites do not meet the code’s criteria, send the report back to the physician for an addendum. In this case, you would send the report back with a note to include documentation of the upper abdominal aorta.