Radiology Coding Alert

Question: I have a procedure note that lists the procedure as a complete right shoulder joint ultrasound (US). The radiologist issued a finding of a supraspinatus tear of the right shoulder.

What elements are required to be documented to report a complete joint US?

Florida Subscriber

Answer: To assign 76881 (Ultrasound, complete joint (ie, joint space and peri-articular soft-tissue structures), real-time with image documentation), the provider must view and document several joint elements. According to the CPT^® guidelines for complete extremity joint US procedures, the following elements must be examined:

• Joint space
• Peri-articular soft-tissue structures surrounding the joint
• Any identifiable abnormality

The guidelines detail situations where the provider may perform additional evaluations to assess the joint, including dynamic imaging and stress maneuvers.

Additionally, a complete US must include permanently recorded images and a written report that describes each required joint element or a reason as to why the element wasn’t visualized. You’ll assign 76882 (Ultrasound, limited, joint or focal evaluation of other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft-tissue structure[s], or soft-tissue mass[es]), real-time with image documentation) if the provider documents anything less than the required elements for 76881.