Radiology Coding Alert

Question: I have documentation of a non-obstetric transvaginal ultrasound and transabdominal ultrasound. The problem is, I can only find the order for the transabdominal ultrasound. Can I report the transvaginal ultrasound? I'm in a freestanding center.
Connecticut Subscriber

Answer: You should have an order for both to code both, so in this case you should only report the nonobstetric transabdominal ultrasound (76700, Ultrasound, abdominal, real time with image documentation; complete; or 76705, ... limited [e.g., single organ, quadrant, follow-up]).
 
If you had orders for both -- or an order for the transvaginal US if the transabdominal US was nondiagnostic for that particular patient -- CPT guidelines tell you that you may report 76830 (Ultrasound, transvaginal) in addition to the appropriate nonobstetric transabdominal ultrasound.
 
Smart: The radiologist should seek a new order from the treating physician when he thinks he should perform a different diagnostic test because the test is inappropriate or doesn't offer a diagnosis.
 
Exception: Medicare does offer an "Additional Diagnostic Radiology Test Exception," stating that if you can't reach the treating practitioner to change the order, you may furnish the additional test if:
 • you perform the ordered test
 • the interpreting physician determines and documents that abnormal test results make the additional test medically necessary
 • delay would harm patient care
 • you send the treating physician the test result and he uses it in the treatment
 • the radiologist documents the reason for the additional tests.

 The radiologist may also determine test design if it isn't specified, modify an order that has clear errors, and cancel a test if the patient's condition requires it. (Get the specific language at www.cms.hhs.gov/transmittals/downloads/R1725B3.pdf.)