Urology Coding Alert

It all comes down to the equipment your provider used.

Out of all the ultrasound procedure codes related to urology, only four specify “duplex scan.” These same four codes also are the only ones focused on studying blood flow:

• 93975, Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study
• 93976, … limited study
• 93980, Duplex scan of arterial inflow and venous outflow of penile vessels; complete study
• 93981, … limited study.

Read on to rediscover what “duplex” represents for your coding and how to differentiate between complete and limited studies.

Get Familiar with Duplex Terminology

In many instances, the term “duplex” is synonymous with double-sided. From an ultrasound coding perspective, however, “duplex” refers to the testing techniques rather than anatomic location.

A duplex ultrasound refers to the combination of the typical grayscale ultrasound and color Doppler ultrasound. The color Doppler capability is built into the same machine. Because of the different colors its images show for motion, color Doppler technology is especially useful in assessing blood vessels and blood flow to urologic organs.

FYI: Urologists frequently use Doppler duplex scans to identify testicular torsion (93975) and to determine the excision site for a partial nephrectomy (93976).

Coding help: When making sure the dictation report includes all the necessary features to code for a duplex scan, you will first want to turn your attention to the technique. For example, with code 93975 you’ll be looking for documentation of the technique similar to: “Complete renal real-time scan with image documentation. Renal vessels and abdominal aorta are evaluated color-flow and spectral waveform analysis Doppler.”

Key point: The provider documents the terms grayscale imaging, spectral analysis, and color Doppler flow.

“Depending on the provider, you may come across words that you can use interchangeably with a term like ‘spectral,’” adds Lindsay Della Vella, COC, owner and founder of Midnight Medical Coding in Boothwyn, Pa. “You will find that this rule applies to numerous different terms found in a duplex scan dictation report. For example, you may consider terms such as ‘wave’ or ‘waveform,’ ‘resistance,’ ‘pulse,’ ‘RI,’ ‘resistive index,’ and ‘flow velocity’ as one in the same with ‘spectral analysis.’”

Best bet: “Make sure the physician includes one of these terms in addition to ‘color flow’ and ‘grayscale Doppler’ to support the coding of a duplex scan,” Della Vella reiterates. If you cannot identify these three terms, send the report back to the provider for review.

Remember: In some cases, you may find some of these terms in the findings and/or technique portions of the note. “Ideally, the provider will include each of these three parameters in both the technique and the body of the report,” explains Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, NY.

“It is important that the provider elaborates on each of these three technical aspects in the findings for compliance purposes,” Rosenberg says. For example, your provider might record a statement such as ‘The main renal vein is patent and demonstrates a normal waveform’ in the body of the report.”

Understand ‘Limited’ vs. ‘Complete’ Designation

Each of the duplex scan codes also designate that the test is either “limited” or “complete.” You will need to pay attention to additional details to determine which code best coincides with the urologist’s service.

Complete exam: To bill for a complete ultrasound exam, the provider normally must document that all items and organs described by the code were imaged and noted. If an organ or item is not imaged or described, the reason for that must also be documented (such as the organ was removed during a previous surgery).

Take note: The rules are a bit different when you’re reporting abdominal/pelvic/retroperitoneal duplex scans. According to the American Academy of Radiology (ACR), the coding of a complete duplex scan does not hinge on the number of organs the physician examines. Instead, the ACR explains that you can report a code such as 93975 “whether single or multiple organs are studied. It is a “complete” procedure in that all major vessels supplying blood flow (inflow and outflow, with or without color flow mapping) to the organ are evaluated.”

Limited exam: You’ll choose limited exam codes 93976 or 93981 if the provider’s documentation does not support the complete exam code.

Correlate the Correct Diagnosis

Insurers rarely pay for renal Doppler ultrasound without specific documentation supporting particular ICD-10 diagnosis codes. These include conditions such as:

• N28.0 – Ischemia and infarction of kidney
• I70.1 – Atherosclerosis of renal artery
• I77.0 – Arteriovenous fistula, acquired
• Q27.1 – Congenital renal artery stenosis
• Q27.2 – Other congenital malformations of renal artery
• Q27.4 – Congenital phlebectasia
• S37.061A – Traumatic fracture of the right kidney
• S37.062A – Traumatic fracture of the left kidney.

Take note: As you can see, the above diagnoses relate to renal (kidney) blood flow and to pathological processes associated with compromised flow to an organ or secondary to organ injury.

Renal Doppler ultrasound may assess arterial and venous patency, perforation of segments in traumatic fracture of a kidney, suspected renal artery stenosis as cause of hypertension, and suspected intraoperative traumatic arteriovenous malformation after percutaneous intrarenal surgery, such as percutaneous nephrostolithotomy.

Final note: Doppler studies are rarely paid when used only to document an unknown structure as vascular. The use of a simple hand-held device that does not produce a hard copy or does not produce a record for analysis of bidirectional vascular flow, is considered to be a part of the physical examination and not separately reportable or billed.