How Many Structures Need to Be Visualized for a Complete Ultrasound?
Question: A 44-year-old patient presented to a radiology practice with an acute knee injury, sustained while playing with their kids. There were no open wounds, and previous X-rays were negative for fractures. The patient is here for a knee ultrasound to evaluate the meniscus, tendons, and ligaments for injury. A radiologist performed an ultrasound on the right knee and noted visualization of the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL), as well as the tendons, cartilage, and lateral and medial menisci. The radiologist determined that the patient tore their medial meniscus. Which CPT® codes do I need to report? North Dakota Subscriber Answer: For your situation, you’ll assign 76882 (Ultrasound, limited, joint or focal evaluation of other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft-tissue structure[s], or soft-tissue mass[es]), real-time with image documentation) to report the right knee ultrasound. You can also append modifier RT (Right side) to the code to specify that the radiologist performed the procedure on the right knee. Code 76882 is the best code for this procedure because the radiologist visualized a portion of the joint and not every structure within the joint. According to CPT® Assistant, Volume 26, Issue 9, “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.” You indicated the physician visualized the ligaments, tendons, cartilage, and menisci of the knee, but did not evaluate the nerves, muscles, and other tissues around the joint. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
