Radiology Coding Alert

Is modifier 52 necessary? Find out.

Read on to learn how to properly code complete and limited ultrasounds.

Receive a Detailed View of Limited Ultrasounds

The codes in the Diagnostic Ultrasound section of the Radiology chapter are organized by anatomic region, and each anatomic subsection’s guidelines provide information about which body structures make up a complete ultrasound for that region. “The difference between a complete ultrasound versus a limited ultrasound boils down to the amount of detail you are looking for,” says Kristen Bensel, CPC, CPMA, CDEO, medical coder of Yellowhawk Tribal Health Center in Pendleton, Oregon.

For example, if a patient’s laboratory findings showed elevated liver enzymes, a provider may order an abdominal ultrasound to evaluate the organs and structures. If the provider orders a limited ultrasound, they can get information about a specific target area. “They are increasing the level of detail they have at their disposal to better treat the patient’s condition,” Bensel says.

Remember Documentation Determines the Code

Each complete ultrasound code must have documentation that includes the anatomic elements that make up the complete exam. At the same time, if the radiologist receives an order to perform a complete ultrasound, but is unable to view one or more elements, then the radiology report should document why the element(s) couldn’t be viewed. Reasons that anatomic structures are unable to be viewed include the element was obscured by bowel gas or the structure was surgically absent.

If the documentation describes all the elements of a complete exam, even if some elements are unable to be viewed, then you may report a complete ultrasound code. “You do not use modifier 52 (Reduced services) on a complete ultrasound code — an ultrasound is either complete or limited. If any element that is required for a complete ultrasound is missing, the limited code should be assigned. The only exception is when the radiologist mentions the reason for nonvisualization,” says Stacie L. Buck, RHIA, CCS-P, RCC, RCCIR, CIRCC, president and senior consultant of RadRx in Stuart, Florida.

If the radiology report notes the provider performed a focused view of a certain body structure or area, then you’ll assign a limited ultrasound code. So, you might assign either a complete or a limited ultrasound CPT^® code for ultrasound procedures performed on the abdomen and breasts depending on what was done.

Here’s what to look for before you assign a code.

Choose the Correct Code for an Abdominal Ultrasound Procedure

The abdomen houses several organs that are part of the urinary and digestive systems. CPT^® code 76700 (Ultrasound, abdominal, real time with image documentation; complete) is a complete abdominal ultrasound. For a radiologist to receive reimbursement for 76700, they need to document scans of the liver, gallbladder, common bile duct, pancreas, spleen, kidneys, and the upper abdominal aorta and inferior vena cava. In other words, when a provider performs an ultrasound of the abdomen, they need to visualize all the organs for you to report 76700. However, if the radiologist receives an order to image one or more abdominal structures, but not all of the elements of a complete exam, then you’ll assign 76705 (… limited (eg, single organ, quadrant, follow-up)) to reflect a limited abdominal ultrasound.

Scenario: A patient presents to your radiology practice for a complete abdominal ultrasound. The patient attested to undergoing a cholecystectomy 10 years ago. The radiologist makes notes of each organ required for the complete abdominal ultrasound, including a note that the gallbladder was absent.

When coding this encounter, you can correctly assign 76700 for the complete abdominal ultrasound. “While the radiologist couldn’t image one element, the attempt was made. Documentation will indicate why that element wasn’t able to be imaged, which is equally as important for the provider treating the patient, as it is to justify billing for a complete ultrasound,” Bensel says. The patient’s history and the radiology report should include information regarding the missing gallbladder to support assigning 76700.

Know What Makes up a Complete Breast Ultrasound

For the purpose of radiology exams, breasts are divided into four quadrants. When a radiologist receives an order to perform a diagnostic ultrasound on all four quadrants, that order is considered a complete ultrasound examination of the breast. A complete ultrasound of the breast also includes the retroareolar region and may include an ultrasound examination of the axilla, according to CPT^® guidelines.

If you receive a radiology report where the provider performed a complete breast ultrasound, you’ll assign 76641 (Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete). If the provider performed the procedure on less than all four quadrants and the retroareolar region, then you’ll assign 76642 (… limited).

Are modifiers necessary for bilateral procedures? When you examine the descriptors for 76641 and 76642, you’ll notice the breast ultrasound codes are designated as unilateral (one side of the body) procedures. If the radiologist performs the same type of ultrasound — complete or limited — on both breasts, then you may report two instances of the appropriate code and may append the codes with RT (Right side) and LT (Left side) modifiers. You should check your individual payer preferences to determine how you should report bilateral complete or limited breast ultrasound procedures.