What CPT code

[Kimberley]

Order states RENAL ARTERY US R/O FMD

RENAL DUPLEX ULTRASOUND

The aorta is well visualized? There is no evidence of aortic aneurysm or significant plaque formation. The renal arteries are well visualized. Flow velocities within the main renal arteries are normal. Flow velocities within the arcuate arteries also are normal. RAR on the right is 1.8 and on the left 2.0cm, within normal limits. Resistive indices are normal. The right kidney is 11.9cm and the left 12 cm length. No focal solid renal masses are identified and there is no hydronephrosis. The bladder appears normal.

IMPRESSION: Normal exam without evidence of significant flow-limiting stenosis in the renal arteries.

Thanks.

Kimberley Tober, CPC
Franklin, TN

[dmaec]

looks to me to be a 76770 procedure
Donna

[Kimberley]

Doesn't there need to be mention of the KIDNEYS, ABDOMINAL AORTA, COMMON ILIAC ARTERY ORIGINS AND INFERIOR VENA CAVA in order to bill out CPT 76770 (unless clinical indicates some type of urinary tract pathology then it qualifies for a complete study 76770)? The facility marked 93975 and 76770

Thanks:-)

[dmaec]

it's my understandy this exam includes real time scans of the kidneys, abdominal aorta, common iliac artery origins, and inferior vena cava, including any demonstrated retroperitoneal abnormality. Also, evaluation of the kidneys and urinary bladder are considered a complete retroperitoneal ultrasound.
in your statement it appears to me that they evaluated the kidneys, aorta, arteries, and bladder. This part of it alone should suffice a 76770 - "The right kidney is 11.9cm and the left 12 cm length. No focal solid renal masses are identified and there is no hydronephrosis. The bladder appears normal."
I still believe it's a 76770
but, you'll need to use a modifier when coding both: (per CCI edits)
93975
76770.59

[Kimberley]

I'm sorry but I'm confused on how this can be billed as a complete 76770, per CSI Navigation for Diagnostic Radiology it states:

By CPT definition, a complete retroperitoneal US exam includes documentation of the following structures:

KIDNEYS
ABDOMINAL AORTA
COMMON ILIAC ARTERY ORIGINS
INFERIOR VENA CAVA

Alternatively, if the patient is being examined for URNINARY TRACT PROBLEMS (which in this case they are not), a complete exam can consist of the following:

KIDNEYS
URINARY BLADDER

As with abdominal US, all structures must be documented in order to bill for a complete exam.

Thanks again:-)

[dmaec]

well, if you feel it's a limited - then code out the 76775 - you'll still need a modifier on it if coding the 93975 also.
(I still feel it justifies a complete)