Urology Coding Alert

Question: On a scrotal ultrasound (US) with duplex scan, the provider documents in the duplex scan technique “duplex Doppler of the scrotal contents was performed.” In the findings, the provider documents “normal arterial flow and waveform bilaterally.” The provider also states in the US findings, which is a combined report with the duplex scan, “symptoms and abnormal color Doppler, therefore duplex performed.” Lastly, the impression and findings document no bilateral venous flow. Is this sufficient documentation to report a duplex code with the US?

Rhode Island Subscriber

Answer: To report services 93975 (Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study) or 93976 (Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study), the provider must document both spectral analysis and color Doppler within the report. The provider must document Color Doppler verbatim, but you may use a plethora of synonymous terms in place of spectral analysis. A few of these terms include:

• Acceleration rate
• Bandwidth broadening
• Spectral Doppler
• Waveform analysis
• Peak systolic velocity

In the question, the provider clearly documents “color Doppler” in the US findings. Additionally, the provider documents “normal arterial flow and waveform bilaterally.” While this is clearly a reference to spectral analysis, it doesn’t quite make the cut under the term “waveform” alone. However, the American College of Radiology (ACR) guidelines state that when a physician specifically states that a duplex study was performed in the dictation report, you may report a duplex scan code regardless of whether spectral analysis and color Doppler are reported.

In this example, the provider clearly spells out that they performed a Duplex scan in the technique. The only question that remains is whether you may report a complete duplex scan using code 93975. According to CPT^® Assistant (August 2016), a complete exam involves a complete evaluation of one or more organs, including their arterial inflow and venous outflow. Assuming the physician documents both the left and right testicles, then you may report 93975 in addition to code 76870 (Ultrasound, scrotum and contents). That’s because the provider documents both bilateral arterial testicular inflow and bilateral venous testicular outflow. The documentation provided of the venous outflow is sufficient despite the fact that the provider could not actually identify venous outflow.