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cpt 76856

Minerva Posted Wed 18th of May, 2011 18:15:16 PM

I know that there are some requirement elements to be mention when billing the above cpt. does the report need to clearly states all elements? uterus,adnexal structures, measurement of the endometrium and bladder.

SuperCoder Answered Wed 18th of May, 2011 20:48:45 PM

AMA GUIDELINES:-
Code 76856 includes:description and measurements of the uterus and adnexal structures, measurement of the endometrium, measurement of the bladder (when applicable), and a description of any pelvic pathology (eg, ovarian cysts, uterine leiomyomata, free pelvic fluid).
...
Code 76856 includes (in case of male pelvis): evaluation and measurement (when applicable) of the urinary bladder, evaluation of the prostate and seminal vesicles to the extent that they are visualized transabdominally, and any pelvic pathology (eg, bladder tumor, enlarged prostate, free pelvic fluid, pelvic abscess).

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