Coding ultrasound after endovenablation on legs

Mklaubauf

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Our physician performed a percutaneous endovenous ablation, procedure 36475 on his patient. Two weeks later patient returns on a follow up visit. The patient is still having some pain so my physician did a ultrasound exam on the leg in the office. We own the ultrasound machine. Only one leg was done. I don't know if I can code 93971 and if I can code that, what documentation should I be looking for to support that code.

Any help is greatly appreciated.
Marci Klaubauf
 

ARCPC9491

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We do these all time and the patients come back a few weeks later for the ultrasound. These procedures don't have a global period. 93971 is a unilateral study, so it's appropriate for one leg. and since you own the machine, you'd be billing globally for both technical and professional components. The doctor's documentation should state the ultrasound was performed, why, his findings, evaluation of blood flow, any blockages, etc, if any, what he feels is causing the pain...what you would normally do for an ultrasound of this type.
 
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