Limited vs. Complete Ultrasound of the Extremity

Limited vs. Complete Ultrasound of the Extremity

CPT® guidelines prior to the codes 76881 Ultrasound, extremity, nonvascular, real-time with image documentation; complete and 76882 Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific state:

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. Code 76882 refers to an examination of an extremity 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. In addition, the code would be used to evaluate a soft-tissue mass that may be present in an extremity where knowledge of its cystic or solid characteristics is needed.

Additionally, CPT Assistant (September 2016) instructs:

How do you determine when to use the complete vs limited ultrasound codes 76881 and 76882
Answer: Code 76881 … is restricted to reporting ultrasound of a joint. Only a joint contains all of the various components, which would allow for the coding of a complete exam (eg, muscles, tendons, nerves, soft tissue). Ultrasound evaluation of non-joint areas of an extremity (eg, groin, axilla, calf, etc), is not a comprehensive exam. Rather, these are all anatomically focused exams that meet the definition for the limited ultrasound extremity code 76882, Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific.
When a complete ultrasound examination of a specific joint is performed, the exam must include real-time scans of the joint, and a detailed evaluation of the tendons, muscles, nerves, and other soft-tissue structures surrounding the joint, as well as any abnormality identified and documented in the patient’s report.
In comparison, code 76882  is a limited examination of an extremity in which ultrasound is performed on a specific structure within the extremity (eg, tendon, soft tissue) with a focused evaluation on the specific area of concern, as seen from obtained images. Documentation of normal anatomical structure and any pathological findings should be made.

As noted in the introductory guidelines in the CPT 2016 code set before the ultrasound code section: If anything less than the elements required for “complete” examinations are reported, the “limited” code for that anatomic region should be used.
Finally, a “limited” examination of an anatomic region should not be reported for the same session as a “complete” examination of that same region.
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Angela Clements

About Has 16 Posts

Angela Clements, CPC, CPMA, CEMC, CGSC, COSC, CCS, AAPC Approved Instructor, is a physician coding auditor, educator, and consultant at Medkoder. She has over 20 years of experience in the healthcare industry. Clements served on the AAPC NAB as the member relations officer from 2015 to 2018 and served as Region 5 Representative from 2013 to 2015. She is a frequent speaker at local medical managers’ meetings and local chapters for both AAPC and AHIMA.

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