Radiology Coding Alert

Question: I have a radiology report for a female patient that lists the procedure as “Ultrasonography Pelvis.” The radiologist documented visualization of the urinary bladder, uterus, myometrium, endometrium, cervix, bilateral ovaries, pouch of Douglas (POD), and the inguinal regions. The report also mentions “No obvious adnexal lesion is seen.”

I’m new to radiology coding and I’m not sure if I should assign 76856 or 76857 for this encounter.

Louisiana Subscriber

Answer: For this encounter, you’ll want to query the provider for more information on the ultrasound approach. With a transabdominal ultrasound, you’ll assign either 76857 (Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles)) or 76856 (… complete) to report the procedure in the encounter. However, if the radiologist performed a transvaginal ultrasound, you’ll assign 76830 (Ultrasound, transvaginal).

Each ultrasound exam requires the provider to visualize certain body structures or document why the structure couldn’t be visualized. According to CPT^® guidelines, documentation of a complete female pelvic ultrasound examination (76856) must include:

• Measurements and description of the uterus and adnexal structures
• Endometrium measurement
• Bladder measurement (when applicable)
• Description of any pelvic pathology

Limited pelvic ultrasound exam documentation, on the other hand, covers “one or more elements listed in code 76856.” In other words, the provider didn’t document visualization of all the required anatomical structures to fulfill the complete pelvic ultrasound examination.