Radiology Coding Alert

Question: What is the appropriate CPT code for an ultrasound of the aorta to detect an abdominal aortic aneurysm (AAA)?

Michigan Subscriber

Answer: The radiologist most likely performed a limited retroperitoneal ultrasound to look for the AAA. CPT describes this procedure with 76775 (Ultrasound, retroperitoneal [e.g., renal, aorta, nodes], real-time with image documentation; limited).

Watch out: If the patient was referred for a one-time AAA screening following an initial preventive physical examination for Medicare and is included in one of the listed risk categories, you should report G0389 (Ultrasound B-scan and/or real time with image documentation; for abdominal aortic aneurysm [AAA] screening).

The risk categories (patient must meet one) are the following:

• has a family history of abdominal aortic aneurysm

• is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime

• is a beneficiary who manifests other specified risk factors (www.cms.hhs.gov/transmittals/downloads/R1113CP.pdf).

Tip: If the patient was not referred as part of the IPPE, you may need to follow up with the ordering physician's office to see if the exam was truly performed for screening purposes or if the patient has signs or symptoms that suggested an AAA.

-- 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.