One CPT code can be used for multiple organs or anatomic sites in a Radiology facility. Radiology CPT codes fall into two categories: 70000 and 90000. Some medical coders become puzzled when coding MRI or ultrasound CPT codes. For example, if we have to code 76700, 76705, or 76775 for gallbladder, liver, or urinary bladder ultrasound CPT codes, we may become confused. And, a minor coding error in such a high-value procedure can result in payment denial or loss.
The main confusion is between Ultrasound Complete vs Limited Abdomen ultrasound. Let's clear this confusion below in this article.
Ultrasound Complete vs Limited Abdomen
An abdominal ultrasound examination (also known as a sonogram) is an important part of diagnostic care. It is also known as a stomach ultrasound at times. CPT codes for ultrasounds differentiate between a "limited" exam and a "complete" exam.
Complete Abdominal Ultrasound
A complete abdominal ultrasound examination includes real-time scans of the liver, gallbladder, common bile duct, pancreas, spleen, kidneys, abdominal aorta, and inferior vena cava, as well as a demonstration of any abdominal abnormality.
Limited Abdominal Ultrasound
A single organ may require a limited abdominal ultrasound. It is frequently ordered for a single quadrant, such as the right upper quadrant (RUQ) for pain in the right upper abdomen. When a healthcare provider orders this, he or she is more interested in a specific organ, such as the gallbladder or liver.
Ultrasound Complete vs Limited Abdomen CPT code for gallbladder and liver (76705, 76700)
The first imaging test for gallbladder and bile duct abnormalities is ultrasound. This test is non-invasive, does not use dyes, and is painless. We have two CPT codes for coding abdominal ultrasound procedures codes: 76700 and 76705.
We should look for all eight organs on ultrasound such as the gallbladder, liver, common bile duct, two kidneys, aorta, Inferior Vena cava (IVC), pancreas, and spleen. If all of these organs are present, you can code CPT code 76700.
The abdomen is divided into four quadrants: upper right, lower right, upper left, and lower left. You can also code limited ultrasound CPT code 76705 here for each quadrant. As a result, when coding CPT codes 76700 and 76705, you must adhere to the coding guidelines.
For Coding ICD 10 codes, always code the diagnosis depending on the quadrant under examination. For example. if you are coding a procedure code 76705 for the right upper quadrant then, you should code a diagnosis related to that quadrant only, not the disorder related to the lower quadrant.
The primary diagnosis should be from the same quadrant which is ordered, the incidental diagnosis can be coded secondary. Some of the common reasons for the visit and primary diagnosis for gallbladder ultrasound are:
Indications: Abdominal pain, fever, nausea, vomiting, flank pain, jaundice
Primary dx or impression: Cholelithiasis (gallstones), Cholecystitis, gallbladder sludge.
Medical coding example for Gallbladder Ultrasound
Clinical Data: Elevated liver enzymes
Exam: US Abdomen Limited – Right Upper Quadrant
Gallbladder: Within the gallbladder, there is a 5 x 3 mm echogenic focus along the wall which neither moves nor shadows. A second 4 x 3 mm echogenic direction in which neither moves nor shadows are seen. A third focus measuring 5 x 3 mm is also seen which neither moves nor shadows. There are no echogenic foci that move and shadow as is expected with gallstones. No gallbladder wall thickening or pericholecystic fluid. No sonographic Murphy sign was noted.
Common bile duct: Diameter: 5 mm. There is no intrahepatic or extrahepatic biliary duct dilatation.
Liver: No focal lesion identified. Liver echogenicity is overall mildly increased.
Impression: There are 3 echogenic foci in the gallbladder, the largest measuring 5 These foci are felt to represent polyps. Given this finding, a follow-up study in approximately 1 year to assess for stability would be advisable. No echogenic foci move and shadow as is expected with gallstones seen. No gallbladder wall thickening or pericholecystic fluid.
Increased liver echogenicity is most likely indicative of a degree of hepatic steatosis. While no focal liver lesions are identified, it must be cautioned that the sensitivity of ultrasound for focal liver lesions is diminished in this circumstance.
CPT: 76705 (only 3 organs)
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