Radiology Coding Alert

Question: What elements does a provider need to document to report a complete nonobstetrical pelvic ultrasound?

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Answer: According to the guidelines preceding the Nonobstetrical subsection of the Radiology chapter in the CPT^® code set, the following elements need to be evaluated and documented, depending on the patient:

• Female pelvic anatomy: Description and measurements of the uterus and adnexal structures, measurement of the endometrium, measurement of the bladder, and a description of pelvic pathology
• Male pelvic anatomy: Evaluation and measurement of the urinary bladder, evaluation of the prostate and seminal vesicles, and any pelvic pathology Unlike an obstetrical ultrasound, providers can perform a nonobstetrical pelvic ultrasound on both female and male patients to evaluate pelvic body structures. You’ll assign 76856 (Ultrasound, pelvic (nonobstetric), real time with image documentation; complete) for a complete nonobstetrical pelvic ultrasound if the preceding elements are documented (or their absence is documented).

However, if the radiologist performs a focused examination of one or more elements listed in 76856, then you’ll assign 76857 (… limited or follow-up (eg, for follicles)) to report a limited nonobstetrical pelvic ultrasound. You may also assign 76857 if the provider reevaluates one or more pelvic abnormalities that were discovered on a previous ultrasound.