Radiology Coding Alert

Question: Which codes should I use for soft tissue ultrasounds of the chest, upper back, lower back, head, and abdomen?

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Answer: CPT^® code definitions will help you choose some of these codes, while the May 2009 CPT^® Assistant will offer you support in choosing codes for others.

Head: The definition of 76536 (Ultrasound, soft tissues of head and neck [e.g., thyroid, parathyroid, parotid], real time with image documentation) indicates it’s the proper choice for a head ultrasound.

Chest: The proper code for a chest ultrasound is 76604 (Ultrasound, chest [includes mediastinum], real time with image documentation). The May 2009 CPT^® Assistant clarifies that you don’t have to see examination of the mediastinum (tissues and organs between the sternum and spine) for this code to apply.

Abdomen: Your abdomen code choice will depend on whether the exam meets the requirements for a complete exam (76700, Ultrasound, abdominal, real time with image documentation; complete) or a limited exam (76705, … limited [e.g., single organ, quadrant, follow-up]).

Back: For the upper back, the May 2009 CPT^® Assistant instructs you to use chest code 76604. The same article states limited abdominal code 76705 is correct for a lower back ultrasound.

Don’t double-dip: When choosing your codes, keep in mind the services actually performed and the range of services each code is designed to represent. For instance, if the patient has an ultrasound of the abdominal wall and lower back, which are in the same general area, the May 2009 CPT^® Assistant states a single unit of 76705 will suffice.