Radiology Coding Alert

Question: Our physician documented the following for a perimenopausal patient who had a previous history of hysterectomy and now undergoes a Doppler imaging which reveals two small simple cysts in the left ovary and both ovaries demonstrated normal blood flow on color and spectral Doppler imaging:

“Transabdominal imaging did not adequately evaluate pelvic structures. The patient’s bladder was not adequately distended, additional transvaginal imaging was performed. There are no comparisons. The uterus is surgically absent. The right ovary is identified, measuring 3 x 1.1 x 2.1 cm. There is normal color Doppler blood flow in the right ovary and paraovarian region and there is normal spectral Doppler waveform in the right ovary, arterial and venous flow identified.

The left ovary measures 2.6 x 1.7 x 2.2 cm. There are two anechoic left ovarian lesions adjacent to each other. Both appear to be simple cysts. One measures 1.4 x 1.4 x 0.8 cm and the other measures 1.5 x 1.3 x 1.3 cm. The left ovary and paraovarian region demonstrates normal color Doppler blood flow. The left ovary demonstrates normal spectral venous and arterial Doppler waveforms.

There is no pelvic free fluid.”

Please suggest the right codes for this procedure. Is it appropriate to submit code 76830 and 93975? Can we append 52 modifier on code 93975?

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