Christopher Posted Fri 21st of October, 2011 19:43:25 PM
In CPT Assistant May 2009 pg 7 it states that “for an ultrasound study to be separately reported, there must be a thorough evaluation of organs or anatomic region”. What is considered a thorough evaluation in a limited ultrasound for an Emergency Room Physician? Please give an example of both a complete and limited “thorough” evaluation of an ultrasound. Thank you for your assistance.
SuperCoder Answered Mon 24th of October, 2011 07:45:20 AM
A complete ultrasound exam is one that attempts to visualize and diagnostically evaluate all of the major structures within the anatomic region. For example, a complete abdominal ultrasound (76700) would consist of real time scans of the: liver, gall bladder, common bile duct, pancreas, spleen, kidneys, upper abdominal aorta and inferior vena cava including any demonstrated abdominal abnormality.
Many emergency department ultrasounds are more focused than "complete." As defined by CPT, a limited ultrasound exam is one in which less than the required elements for a complete exam are performed and documented. Given the nature of of the focused ED ultrasound examinations, the limited codes are typically the most accurate for utilization in the ED setting. For example, an abdominal ultrasound used to evaluate the presence of an abdominal aortic aneurysm would be reported as a "limited retroperitoneal ultrasound" (76775).
The one common exception to the rule is the transvaginal ultrasound in the pregnant (76817) and non-pregnant (76830) patient, where there is no corresponding limited procedure CPT.