Wiki 76805 VS 76815

[bkemp15628]

I have a question on 76805. According to the below should I keep using the 76815 instead of the 76805?

I down code 76805 to 76815 because of the Codingstrategies navigator and American College of Radiology statement that: If the maternal adnexa are not visible, the radiologist should document this information in the report. I have pointed this out when I am told that it is wrong. My co-workers point out the CPT Professional book's last line states: when visible, examination of maternal adnexa. Therefore if everything is mentioned that should be mentioned for the baby use 76805. They also state the doctor orders and the exam title state US OB complete after 1st trimester. We don't see the doctor orders and the radiologist doesn't always pick the correct exam titile. Am I wrong in downcoding it after being ignored in pointing this out several times because it isn't in the report?

 

[ROBINHB]

Hi Bkemp15628,
To me this would be an education piece for your ultrasound staff. Since 76805 & 76810 do include assessment of the maternal adnexa (when visible) to meet the documentation requirements of the ultrasound, it would be appropriate for your ultrasound techs to either document the results of the adnexal assesssment or to document that they cannot visualize the adnexa at this time.

 

[thomas7331]

I agree with Robin that this should be an education item. If they are performing a complete exam as ordered but failing to appropriately document that one element, that is a documentation issue and it is not solved by down coding. This is not like an E&M code where you are assigning a level based on documentation - in this case, the code assignment should match the procedure actually ordered and performed. If the documentation is deficient, then it should be returned for completion. In my opinion, changing the code to a bill for a less comprehensive test due to a minor documentation oversight is not the correct way to represent the work done, unless your facility's management has established such a policy and given you the go-ahead to do this.