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When coding a US retroperitoneal Complete for US kidneys ureters bladder, my sonographers tell me that nine times out of ten, the ureters in most patients are not visible unless there is hydronephrosis. If we image the kidneys and bladder but the ureters are not seen and charge a complete, should the radiologist dictate ureters are not visualized so we can charge a complete (code 76770)?
For those anatomic regions that have “complete” and “limited” ultrasound codes, note the elements that comprise a “complete” exam. The report should contain a description of these elements or the reason that an element could not be visualized (eg, obscured by bowel gas, surgically absent). So if your radiologist dictates why they were not visualized, this would support a complete examination.
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