Radiology Coding Alert

Question: Do transvaginal and transabdominal ultrasounds (US) performed at the same encounter need to be separated by paragraphs?

Mississippi Subscriber

Answer: There are no definitive guidelines here that mandate that the transvaginal and transabdominal dictation reports be distinct from one another. The radiologist should document each respective route in the technique and findings of the report. Typically, the radiologist will separate the findings of the transvaginal route from the transabdominal route within the findings with separate paragraphs. If the physician does not specifically document one of the two routes (transvaginal/endovaginal or transabdominal), then you should send the report back for an addendum.

Coder’s note: Keep in mind that you should still typically see two reports for transvaginal and transabdominal US procedures. In most instances, these reports will be identical, including both interpretation of both the transabdominal and transvaginal scans. The exam header of the report will be different, but the indication, technique, findings, and impression will remain consistent.