Urology Coding Alert

Start by distinguishing ‘complete’ from ‘limited.’

Physicians use renal ultrasounds to assess the size, shape, and location of a patient’s kidneys and to assess pathological processes that may involve the kidneys. Ultrasound can help the physician determine needle placement for biopsies or tubes for drainage. Ultrasounds can detect renal cysts, calculi, tumors, abscesses, obstruction, fluid collection, and infection within or around the kidneys.

With so many potential uses of renal ultrasound, it’s important to know the ins and outs of documentation and coding. Read on for a refresher on how you can support the service and be appropriately reimbursed.

Document All the Details

One of your first steps in coding ultrasounds is to verify whether the test was limited or complete. According to CPT^® guidelines, “If less than the required elements for a ‘complete’ exam are reported (e.g., limited number of organs or limited portion of region evaluated), the ‘limited’ code for that anatomic region should be used once per patient exam session.” For a renal ultrasound you should report 76775 (Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; limited).

Other info: The more details the physician can include in his documentation, the more successful your coding will be. Items that should be included when documenting renal sonograms are:

• Evaluation of the upper, mid, and lower poles of each kidney in sagittal and transverse views
• Sagittal view to evaluate the cortex and renal sinus
• Renal length measurements of both kidneys
• Comparison of echogenicity of the kidney with adjacent structures (liver and spleen)
• Documentation of any abnormalities seen
• Renal parenchyma measurement, if indicated.

Remember the Doppler Difference

Sometimes the urologist will choose to perform a Doppler ultrasound, also known as a duplex study. Doppler ultrasound allows the physician to assess renal arterial and venous patency and check for suspected conditions such as renal artery stenosis. Associated diagnoses might include any of the following:

• N28.0 – Ischemia and infarction of kidney
• I70.1 – Renal artery stenosis
• I77.0 – Arteriovenous fistula, acquired
• Q27.1 – Congenital renal artery stenosis
• Q27.2 – Other congenital malformation of renal artery
• Q27.4 – Congenital phlebectasis
• S37.061A – Traumatic fracture of the right kidney
• S37.062A – Traumatic fracture of the left kidney.

Correct coding for Doppler/duplex vascular study of the kidneys includes reporting:

• 93976 – Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study
• 76775 – Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; limited.

Remember: Append modifier 59 (Distinct procedural service) to 76775 on your claim to differentiate the ultrasound test from the imaging Duplex scan. CPT^® code 76775 is bundled into code 93976, but may be unbundled and paid with the above modifier.

Take note: Insurers rarely pay for renal Doppler ultrasound without specific documentation with the above diagnostic ICD-10 codes.

Know When Complete Retroperitoneal US Applies

Before finalizing your claim, remember one more important clinical and coding point for Medicare and other insurers.

“According to CPT^® (Current Procedure Terminology), CMS (Medicare), and the American College of Radiology (ACR), for patients with a clinical history suggesting urinary tract pathology, sonographic evaluation of both the kidneys and urinary bladder at the same encounter should be coded as a complete retroperitoneal ultrasound,” said Michael A. Ferragamo, MD, FACS, clinical assistant professor at the State University of New York at Stony Brook. 

Therefore, the correct code to report would be 76770 (Ultrasound, retroperitoneal [e.g., renal, aorta, nodes], real time with image documentation; complete).

Take note: Many payers (but not all) as well as Medicare will not pay for both renal (76775) and bladder (76857, Ultrasound, pelvic [nonobstetric], real time with image documentation; limited or follow-up [e.g., for follicles]) sonograms reported at the same time. ICD-10 diagnostic coding can include kidney or bladder pathological diagnoses.

This urinary tract pathology exception is important because otherwise 76770 would require “real time scans of the kidneys, abdominal aorta, common iliac artery origins, and inferior vena cava, including any demonstrated retroperitoneal abnormality,” CPT^® guidelines state.