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Outpatient Facility Coding Alert

You Be the Coder:

Refer to Anatomical Criteria List When Coding 76770, 76775

Question: I am having trouble deciding between 76770 and 76775 on a report I am reading. The findings only make references to the kidneys, besides one single additional line stating “bilateral ureteral jets are seen.” Is this enough to code as 76770?

Washington Subscriber

Answer: There are two different ways in which the documentation can steer you toward code 76770 (Ultrasound, retroperitoneal [eg, renal, aorta, nodes], real time with image documentation; complete). The first is if the provider documents each of the following anatomical criteria:

  • Kidneys,
  • Abdominal aorta,
  • Common iliac artery origins, and
  • Inferior vena cava.

The CPT® manual also states that “if clinical history suggests urinary tract pathology, complete evaluation of the kidneys and urinary bladder also comprises a complete retroperitoneal ultrasound (US).”

In your example, there is no documentation of the bladder, abdominal, aorta, common iliac artery, or inferior vena cava. Therefore, you will have to resort to reporting code 76775 (Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited).

Knowledge check: Documentation of the ureters is actually not necessary for either complete or limited retroperitoneal ultrasounds. According to Clinical Examples in Radiology (Summer 2013), normal ureters are typically too small to be properly visualized using ultrasound imaging.