Kathy Posted Mon 19th of November, 2018 11:09:14 AM
When a physician is dictating Doppler studies I know that they must include, grey scale, spectral Doppler and color flow. Are they required to state arterial inflow and venous outflow in order for it to be considered a Doppler? what are some synonymous terms that can document arterial inflow and venous outflow. Can you supply me with documentation that I can present to my physicians?
SuperCoder Answered Tue 20th of November, 2018 02:20:08 AM
Thank you for the Question.
A duplex scan is a noninvasive vascular diagnostic study--an ultrasonic scanning procedure display of the following:
• the two-dimensional structure of the target analysis and the vessels' motion with time
• the Doppler ultrasonic signal of the flowing blood.
Documentation of the results of all duplex scan studies should reflect the assessment of flow with color and recording a spectral waveform. Spectral Doppler in the radiologist’s documentation should have information regarding Spectral, Flow velocity, RI, Resistance, Wave, Pulse(d), Resistive index
For example, documentation that would support billing a Duplex scan CPT code would be, “Duplex scan was performed using B-Mode/gray scale imaging and Doppler spectral analysis and color flow.”
• a Limited Duplex Scan, the documentation must at least include: Color and Spectral Doppler
• Complete Duplex Scan, the documentation must include: Arterial inflow & Venous Outflow and Color & Spectral Doppler
Duplex Scans of the abdomen, pelvic, scrotum and/or retroperitoneum can also be performed and reported as complete or limited studies. Complete studies require that the radiologist examine and document both sides of a paired organ, such as the ovaries.
• If flow is not visualized (ie, torsion) the documentation should reflect that the spectral Doppler evaluation revealed no flow.
• Documentation should reflect the information about waveform that appears normal.
Hope this helps!