Radiology Coding Alert

Question: I have documentation of limited abdominal vascular imaging (arterial and venous) for thrombus. The documentation also notes Doppler imaging of the inferior vena cava. Which codes describe this?

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Answer: Based on the limited amount of information in the question, you should start your search by looking at 93978 (Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study) and  3979 (... unilateral or limited study).

A duplex scan is a noninvasive vascular diagnostic study -- an ultrasonic scanning procedure display of the following:

• the two-dimensional structure of the target analysis and the vessels' motion with time

• the Doppler ultrasonic signal of the flowing blood.

Documentation must: You need full documentation of these anatomic and physiologic parameters to report these codes. The documentation also should include a spectrum analysis and/or color flow mapping or imaging of the flowing blood.

Complete code 93978 is appropriate if you have documentation of a complete scan of any one of the listed areas (such as the inferior vena cava).

ICD-9: The diagnosis code will depend on whether the radiologist documents thrombus (such as, 453.2, Other venous embolism and thrombosis; of vena cava) or you have only documented signs and symptoms to report.

-- The answers for You Be the Coder and Reader Questions were reviewed by Michele Midkiff, CPC-I, PCS, RCC, executive director of Coding Affiliates Inc., an interventional and neuro-interventional radiology coding service in Mountain View, Calif.