Urology Coding Alert
Turn to Unlisted Code for 3D Translabial US
Question: Our urogynecology provider is entertaining the idea of performing 3D translabial ultrasounds. They will be reviewing the pelvic floor and rectal muscles using still images of the anatomy, to watch for dynamic changes in the rectal wall, such as out-pouching or herniation. They just place the transducer on the outside anatomy. They do not enter the vagina or rectum. I have done some research and found on the AUGS website a suggestion to use either 76376 or 76377. Are these the correct codes for this procedure?
Virginia Subscriber
Answer: There is no CPT® code for the sonographic studies your urogynecologist plans to perform. For your clinical scenario, first report 76999 (Unlisted ultrasound procedure [eg, diagnostic, interventional]) for the external study. Bench mark the unlisted procedure with 76856 (Ultrasound, pelvic [nonobstetric], real time with image documentation; complete).
Then, report 76376 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation) for the 3D rendering.
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