Appropriate Coding of Ultrasound in Urology
- Diagnostic Ultrasound Reports
- Explanation of Specific Ultrasound CPT® Codes
- Prostate-Ultrasound and Ultrasonic Guidance Procedures
- Ultrasound Addition
All diagnostic ultrasound procedures should be summarized in a separate, written paragraph. The results must be documented in the patient's chart with any permanently recorded images with measurements (when clinically indicated). Individual carriers may have their own requirements as to whether the report should be documented on a separate piece of paper in the patient's chart or commented on separately in the office notes or operative notes. When ultrasonic guidance is performed in conjunction with another urological procedure (e.g., sonographically-guided needle biopsy of the prostate), the final written report for the ultrasound may be included within the report of the urological procedure.
CPT® describes several ultrasound procedures as either a complete or limited examination. To qualify as a complete examination, the specific requirements and elements of an anatomical region must be met. The corresponding report must contain a description of all of the elements of a complete exam or, if lacking, the reason that an element could not be visualized (e.g., obscured by bowel gas, surgically absent, etc.). If all of the required elements for a "complete" examination are not captured, then the "limited" procedure must be reported. Do not report a limited examination during the same examination session as a complete examination of the same region. The anatomical areas comprising a complete examination will be discussed in more detail below.
If there is not a thorough evaluation of organ(s) or anatomic region, image documentation and a final written report, the use of the ultrasound is not separately reportable. This does not apply to CPT® code 51798 as there is no image documentation. It is reportable separately.
If the ultrasound procedure is performed with a machine not owned by the urologist, it is appropriate to append modifier -26, Professional Component, to the procedure.
- Doppler evaluation of vascular structures
- Post-voiding Residual Urine
- Prostate Biopsy
- Scrotum and Contents
- Unlisted Ultrasound
Doppler Evaluation of Vascular Structures (other than color flow used for anatomical structure identification) is used; report the appropriate non-invasive vascular diagnostic studies code in the Medicine Section of CPT®. For urology, these codes include:
|93975||Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study|
|93976||Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study|
|93980||Duplex scan of arterial inflow and venous outflow of penile vessels; complete study|
|93981||Duplex scan of arterial inflow and venous outflow of penile vessels; follow-up or limited study|
|51798||Measurement of post-voiding residual urine and/or bladder capacity by ultrasound; non-imaging|
Another source of confusion for coders is the wording of CPT® code 51798; specifically the term "non-imaging." The Coding and Reimbursement Committee of the AUA reviewed this issue and decided that regardless of the type of ultrasound machine used or whether an image was obtained, if the intent of the diagnostic procedure is to obtain only a post-voiding residual urine, then CPT® code 51798 is appropriate.
|76700||Ultrasound, abdominal, real time with image documentation; complete|
A complete ultrasound examination of the abdomen consists of scans of: the liver, gallbladder, common bile duct, pancreas, spleen, kidneys and the upper abdominal aorta and inferior vena cava including any demonstrated abdominal abnormality.
A separate written report should include comments on all these organs and elements and the findings. If particular elements cannot be visualized, the reason should be documented.
|76705||Ultrasound, abdominal, real time with image documentation, limited (e.g., single organ, quadrant, follow-up)|
This "limited" CPT® code captures a focused examination in the assessment of one or more elements listed in the "complete" ultrasound above. If you do not visualize all the elements outlined in the "complete" description, the limited CPT® code 76705 should be used.
A separate written report should be included in the patient's chart as well as any images obtained during the ultrasonic procedure.
|76770||Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; complete|
A complete ultrasound of the retroperitoneum consists of scans of: the kidneys, abdominal aorta, common iliac artery origins and inferior vena cava, including any demonstrated retroperitoneal abnormality. If the clinical history suggests urinary tract pathology, a complete evaluation of the kidneys and urinary bladder also comprises a complete retroperitoneal ultrasound. Therefore, it is not appropriate to report additional ultrasound codes (such as abdominal or pelvic) for an evaluation of the kidneys and bladder.
|76775||Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; limited|
This "limited" CPT® code captures a focused examination in the assessment of one or more elements listed in the "complete." If all of the specified elements outlined in the "complete" description are not visualized by ultrasound and documented, then the "limited" CPT® code 76775 should be used. A separate, final written report should be included in the patient's chart as well as any images obtained during the ultrasonic procedure.
|76856||Ultrasound, pelvic (nonobstetric), real time with image documentation; complete|
Pelvic ultrasound codes are used for both female and male anatomy.
Elements of a complete female pelvic examination include a description and measurement of the uterus and adnexal structures, endometrium, bladder, and of any pelvic pathology (e.g., ovarian cysts, uterine leiomyomata, free pelvic fluid).
Elements of a complete male pelvic examination include the evaluation and measurement (when applicable) of the urinary bladder, prostate and seminal vesicles to the extent they are visualized transabdominally, and any pelvic pathology (e.g., bladder tumor, enlarged prostate, free pelvic fluid, pelvic abscess).
A separate written report should comment on all the findings of these organs. If particular elements cannot be visualized, the reason should be documented.
|76857||Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (e.g., for follicles)|
This "limited" CPT® code captures a focused examination in the assessment of one or more elements listed in the "complete" pelvic ultrasound CPT® code 76856. It also captures the reevaluation of one or more pelvic abnormalities previously demonstrated on ultrasound. A separate written report should be dictated and included in the patient's medical chart.
This code should be selected if the urinary bladder alone (not including the kidneys) is imaged (real time). Do not use CPT® code 76770. If post-voiding residual urine is obtained and the imaging of the bladder is obtained but not medically necessary, use CPT® code 51798 as discussed above.
It is the standard of care to perform a sonographic evaluation of the prostate for any abnormality prior to a prostate biopsy. These abnormalities will be shown as hypoechoic areas or lesions that need further diagnostic investigation. This sonographic evaluation determines whether the physician should continue with prostate biopsy. A separate report for this diagnostic evaluation is required. This formal report should be signed by the physician and included in the patient's chart.
|76942||Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation|
As described above, if there are questionable areas the physician will normally continue with the sonographically guided biopsy of the prostate. To obtain specimens of the questionable areas, it is important that the physician direct the biopsy needle accurately and this type of sonogram is an essential part of the procedure to assure the proper placement of the needle.
In addition to the ultrasound codes, it is appropriate to bill the biopsy code.
It is also important to include a written report on the ultrasonic guidance procedure. This report may be either separately documented or included within the report of the procedure.
The AUA has developed appeal letter templates to help urologists if a carrier denies reimbursement for transrectal ultrasonically performed prostate biopsies or in the event that a carrier declares that ultrasounds must be performed by a radiologist. Contact the Practice Management Department at CodingHotline@AUAnet.org for more information.
|76873||Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure)|
Prior to brachytherapy treatment, a prostate volume study is performed taking 5 mm cuts or pictures to plan where the radioactive seeds are to be placed in the prostate. This study aids the radiotherapist in the placement of the seeds into the catheters or needles for placement in the prostate.
A separate report for this diagnostic evaluation is required that documents the size and volume of the prostate for treatment planning prior to the actual brachytherapy treatment. A formal report is signed by the physician and included in the patient's chart.
|76965||Ultrasonic guidance for interstitial radioelement application.|
This CPT® code captures the ultrasonic guidance necessary to implant the radioactive seeds for brachytherapy treatment. This is normally used with 55875 transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy. This may be billed by the radiation oncologist.
It is also appropriate to include a final written report on the ultrasonic guidance procedure. This report may be either separately documented or included within the report of the procedure for which the guidance is necessary.
In addition to the ultrasonic guidance CPT® code, it is also appropriate to report:
|76870||Ultrasound, scrotum and contents|
This CPT® code describes the sonographic evaluation of the scrotum and its contents. A separate, written report documenting any scrotal abnormalities must be dictated and included in the patient's medical chart.
|76999||Unlisted ultrasound procedure|
|76376||3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image post processing on an independent workstation|
|76377||requiring image post processing on an independent workstation|
The physician provides concurrent supervision for processing of computerized tomography (CT), magnetic resonance imaging (MRI), ultrasound, or other tomographic modality with 3D manipulation of volumetric data sets and imaging rendering. The exact nature of the 3D manipulation is dependent upon the type of study being performed and the purpose of the diagnostic imaging. Image manipulation can include 3D image segmentation (i.e., removing skeletal structure to better visualize vascular structure followed by identifying and segmenting vessels for individual analysis and review, 3D image restoration).