Radiology Coding Alert

Question: How should I code an ultrasound of the right flank soft tissues? The patient had pain and a lump, but the results of the ultrasound were normal.

Louisiana Subscriber

Answer: You should report 76705 (Ultrasound abdominal, real time with image documentation; limited [e.g., single organ, quadrant, follow-up]) to represent the ultrasound.

Requirements: CPT guidelines for abdominal and retroperitoneal ultrasounds state you can report an ultrasound only with "thorough evaluation of organ(s) or anatomic region, image documentation and final, written report."

ICD-9: Because the results were normal, you should report the signs and symptoms documented by the ordering physician as the reason for the test. In this case, you should report 789.0x (Abdominal pain) for the flank pain. For the lump, report 789.3x (Abdominal or pelvic swelling, mass, or lump).