Mike Posted Fri 29th of April, 2016 14:03:49 PM
Ultrsaound was performed on Left inguinal, pubic and hip region. Would CPT code be 76881?
SuperCoder Answered Mon 02nd of May, 2016 02:48:42 AM
A complete ultrasound examination of an extremity (76881) consists of real time scans of a specific joint that includes examination of the muscles, tendons, joint, other soft tissue structures, and any identifiable abnormality.
A limited examination of an extremity (76882) that would be performed primarily for evaluation of muscles, tendons, joints, and/or soft tissues. This is a limited examination of the extremity where a specific anatomic structure such as a tendon or muscle is assessed.
Now depending upon the structure involved in the documentation, we need to select among these two codes. Thank you.
Mike Posted Mon 02nd of May, 2016 10:53:51 AM
You did not answer my question. I know the two codes but would the hip be limited or complete?
Under the tips in 76881 "If the provider performs ultrasound over a specific part of extremity use 76882"
SuperCoder Answered Tue 03rd of May, 2016 08:41:37 AM
Suppose the ultrasound documentation mentions examination of extremity which includes only soft tissues it will go under limited code that is 76882. As per my understanding anatomic structures includes tendon, muscle, joints and soft tissues. Left inguinal, pubic and hip are the regions of lower extremity.
So in your documentation if you see only soft tissue examination of hip you will code 76882. However, if there is mention of tendon, muscle, joints and soft tissues of hip you will code 76881. Further, if inguinal, pubic and hip soft tissues only is examined under ultrasound we will still go for 76882. For more clarity please provide me with some more documentation to be specific. Thank you.
Mike Posted Tue 03rd of May, 2016 13:22:03 PM
ok, I get it.
SuperCoder Answered Wed 04th of May, 2016 00:39:37 AM
Thank you :)