Radiology Coding Alert

Question: One of our gynecologists recommended a complete transabdominal pelvic ultrasound for a patient with unusual menstrual bleeding. The technician performed the ultrasound, but a small uterine mass prevented him from getting a clear view of all the pelvic structures. The radiologist suggested a transvaginal approach for a better image of the inaccessible organs and the uterine mass, and the technician performed this service, too. May I report both services?


Iowa Subscriber


Answer: You may code for both ultrasounds as long as they are both medically necessary and ordered by the gynecologist.

Report 76856 (Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete) and 76830 (Ultrasound, transvaginal). Depending on your payer's rules, you may need to append modifier 51 (Multiple procedures) to 76830.

Why: CPT guidelines say that if you perform a transvaginal examination in addition to a transabdominal nonobstetric ultrasound, you should report 76830 in addition to the appropriate transabdominal exam code. Remember: CMS requires that the treating physician--in this case, the gynecologist--order diagnostic tests. The request and report should convey the medical necessity for both exams.