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Radiology Coding Alert

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Code Post-Hysterectomy US Complete?

Published on Thu Oct 04, 2007

Question: When coding a non-obstetric pelvis ultrasound (US) for a patient who has had a hysterectomy, should I report a limited exam or complete exam?

Missouri Subscriber

Answer: For females, complete nonobstetric ultrasound (76856, Ultrasound, pelvic [nonobstetric], real time with image documentation; complete) includes the following:

  • uterus and adnexal structure description and measurement
  • endometrium measurement
  • bladder measurement (when applicable)
  • pelvic pathology description.

As long as the doctor documents each of the required elements or notes the reason he could not visualize them in the pelvic ultrasound, you may report the "complete" code, according to CPT guidelines for "Diagnostic Ultrasound."

The guidelines include "surgically absent" as a valid reason for not being able to visualize the required elements.

You should report a limited pelvic ultrasound (76857, ... limited or follow-up [e.g., for follicles]) when the doctor limits his assessment to one or more (but not all) of the elements described for 76856 or re-evaluates one or more pelvic abnormalities noted on a previous ultrasound.

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