It’s no secret that many CPT® codes for ultrasounds make a distinction between a ‘limited’ exam and a ‘complete’ exam. From a coding standpoint, it’s made fairly clear that in order to report a complete exam, all required components for the complete exam must be imaged and documented. If even one element out of, hypothetically, five is missing from the report then the limited code choice for the anatomic region in question should be reported for the exam.
What makes ultrasound somewhat unique is the fact that if only four of our hypothetical five required elements are imaged, it is still possible to report, and get credit for, a complete exam – assuming proper documentation.
For example, in order to report a complete abdominal ultrasound, the documentation must include imaging of the liver, gallbladder, common bile duct, pancreas, spleen, kidneys, upper abdominal aorta and inferior vena cava. If one or more of these elements are missing the limited abdominal ultrasound code should be reported.
Evaluation of the abdominal organs was performed. The liver is normal in shape and contour. The gallbladder is not dilated and there is no evidence of stones. The common bile duct is normal with no appearance of dilatation. The pancreas and spleen are normal in size and contour. The kidneys show no evidence of hydronephrosis. The upper abdominal aorta and IVC do not show any aneurysm or stenotic lesions.
Note: The above report represents the complete abdominal ultrasound code, 76700, because all the required elements are noted.
Evaluation of the abdominal organs was performed. The liver is normal in shape and contour. The gallbladder is not dilated and there is no evidence of stones. The common bile duct is normal with no appearance of dilatation. The kidneys show no evidence of hydronephrosis. The aorta and IVC do not show any aneurysm or stenotic lesions.
Note: In the above report, the interpreting physician does not indicate evaluation and findings for the pancreas and the spleen. Therefore, the procedure must be coded as a limited study, code 76705, since all required elements are not described.
Had the interpreting physician included in the report the reason why the missing elements could not be visualized (i.e., obscured by bowel gas, surgically absent, etc.), the complete abdominal ultrasound code may still be reported. If the reasons for missing elements are not documented, then the limited code would be reported.
Differentiating between complete and limited ultrasounds for a variety of anatomic regions and scenarios are among the most common questions we receive. For more guidance, tips, and answers to our most frequently asked ultrasound questions, check out our Ultrasound Coder. Written by prominent authorities on coding for a full range of diagnostic ultrasound, ultrasound guidance, echocardiography, noninvasive vascular and intravascular ultrasound procedures, the book addresses frequently asked questions, as well as common areas of confusion and noncompliance our authors experience firsthand in their audits, trainings and education – bringing their experiences and expertise to you in one easy resource.
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