Radiology Coding Alert

Question: Does a complete renal ultrasound (US) have to include kidneys, ureters and bladder? And does a pelvic US have to include uterus, endometrium, both ovaries and both fallopian tubes? Minnesota Subscriber         Answer: CPT guidelines say that for a complete retroperitoneal ultrasound (76770, Ultrasound, retroperitoneal [e.g., renal, aorta, nodes], real time with image documentation; complete) you need "real- time scans of the kidneys, abdominal aorta, common iliac artery origins and inferior vena cava, including any demonstrated retroperitoneal abnormality." Exception: If the patient's clinical history suggests urinary tract pathology, you may code a complete exam for complete evaluation of the kidneys and urinary bladder. Flank pain (789.0x, Abdominal pain) is a good example of this sort of clinical history, in addition to all of the typical urinary problems, such as dysuria (788.1, Dysuria) and frequency (788.4x, Frequency of urination and polyuria). Pelvic: For a complete, nonobstetric pelvic ultrasound (76856, Ultrasound, pelvic [nonobstetric], real time with image documentation; complete), CPT guidelines require descriptions and measurements of the uterus and adnexal structures, measurement of the endometrium and (when applicable) bladder, and a description of pelvic pathology. Note: "Adnexal structures" include ovaries, fallopian tubes and uterine ligaments, but an auditor would focus on documentation of the patient's ovaries and tubes.