Radiology Coding Alert

Question: How should I code the following report?

History: Lump over the upper right back.

Findings: Real-time gray scale, color, and duplex Doppler imaging is performed for evaluation of a nodule over the upper right back measuring approximately 1.4 x 0.4 x 1.4 cm. Color Doppler imaging demonstrates moderate internal vascular flow. Duplex Doppler imaging demonstrates internal both venous and arterial flow. A large vessel appears to enter the superior margin of the mass. The surrounding fascia planes are well defined. There is an oval nodule that is moderately deep to the skin surface and overlies the musculature, exhibiting both internal arterial and venous blood flow. There appears to be a supplying artery and draining vein. Sonographic characteristics are not compatible with arterial venous malformation although some type of vascular lesion is undoubtedly present. Considerations include a hemangioma, mixed arterial venous malformation, or possibly a mass with high internal vascular flow such as a metastatic deposit from neuroblastoma or other types of soft tissue tumor such as myofibroma or sarcoma. Findings are not definitive.

Florida Subscriber

Answer: Your best bet may be to report 76999 (Unlisted ultrasound procedure [e.g., diagnostic, interventional]) for the duplex and 76604 (Ultrasound, chest [includes mediastinum], real time with image documentation) for the gray-scale.

Gray scale: The May 2009 CPT Assistant says 76604 is appropriate for an ultrasound of an upper-back soft-tissue mass.

Duplex: The duplex does not fit into any of the existing duplex codes, and there is no code for an unlisted duplex study, so 76999 is the most appropriate choice.

Assuming you have the appropriate orders, your documentation should support both a gray-scale ultrasound exam and a duplex study. The radiologist spelled out the types of imaging he used, and the Doppler imaging is more extensive than just a check for flow (which you would include in the gray-scale).

Documentation tip: Experts recommend that the physician break the documentation into two separate paragraphs (one for gray-scale and one for Doppler) to show the two exams clearly.