Radiology Coding Alert

Question: If our radiologist documents kidneys along with their size, mentions bladder or lack of being able to see bladder due to bowel gas, and ureter jets, can we code this as 76770 when the test is for urinary tract indications?

Washington Subscriber Answer: According to the 2005 CPT guidelines, you certainly can.
 
Your report specifies urinary tract indications. For 76770 (Ultrasound, retroperitoneal [e.g., renal, aorta, nodes], B-scan and/or real time with image documentation; complete), if the patient's clinical history suggests urinary tract pathology, a complete evaluation of the kidneys and urinary bladder adds up to a complete retroperitoneal ultrasound.
 
A complete evaluation of the kidneys and bladder means the study fully visualizes all the structures and organs within the anatomic description of that study, unless certain structures remain unvisualized despite the physician's best attempt at visualization. So, if certain structures aren't visible (because of pathology, obstruction, or even surgical removal), you may still code the exam as complete.
 
If you didn't see a history of urinary tract pathology, a complete ultrasound for 76770 would require B mode scans of kidneys, abdominal aorta, common iliac artery origins, and inferior vena cava, including any demonstrated retroperitoneal abnormality.  - The answers for You Be the Coder and Reader Questions were reviewed by Cindy C. Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga.; and Gary S. Dorfman, MD, FACR, FSIR.