Radiology Coding Alert

Question: Should we report a limited or complete abdominal ultrasound when the dictation only mentions one of the patient's two kidneys? The dictation meets every other requirement to be complete.

Texas Subscriber

Answer: If the radiologist only describes one kidney and doesn't explain why he didn't describe the other, you must report a limited exam (76705, Ultrasound, abdominal, B-scan and/or real time with image documentation; limited [e.g., single organ, quadrant, follow-up]).
 
CPT guidelines for diagnostic ultrasounds state that to report a "complete" exam, the report should contain a description of all required elements or must explain why the element couldn't be visualized. Example: The radiologist documents that the organ is obscured by bowel gas or surgically absent.
 
A complete abdominal ultrasound "consists of B mode scans of the liver, gall bladder, common bile duct, pancreas, spleen, kidneys, and the upper abdominal aorta and inferior vena cava including any demonstrated abnormality."

-- The answers for You Be the Coder and Reader Questions were reviewed by Jackie Miller, RHIA, CPC, senior consultant with Coding Strategies Inc. in Powder Springs, Ga.; and Gary S. Dorfman, MD, FACR, FSIR.