Radiology -US extremity

nbohm

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We have various different opinions on how to code this based on the documentation.

It reads:
Right groin pain post cardiac cath 3 days ago.

Findings:
Multiple sonographic images targeting the right groin are submitted for review. There is no measurable mass or fluid collection. There is no evidence for pseudoaneurysm or hematoma. Assessment of the regional vasculature demonstrates vessel patency with normal flow.

Impression:
no convincing evidence for right groin hematoma or pseudoaneurysm

Because it indicates normal flow we ruled out extremity us...but then other codes read duplex scan....it has taken us to 93922. Does anyone have any thoughts on this or another more appropriate code?

Thanks
Nikki
MO
 

donnajrichmond

True Blue
Messages
518
Location
Alexandria, LA
Best answers
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We have various different opinions on how to code this based on the documentation.

It reads:
Right groin pain post cardiac cath 3 days ago.

Findings:
Multiple sonographic images targeting the right groin are submitted for review. There is no measurable mass or fluid collection. There is no evidence for pseudoaneurysm or hematoma. Assessment of the regional vasculature demonstrates vessel patency with normal flow.

Impression:
no convincing evidence for right groin hematoma or pseudoaneurysm

Because it indicates normal flow we ruled out extremity us...but then other codes read duplex scan....it has taken us to 93922. Does anyone have any thoughts on this or another more appropriate code?

Thanks
Nikki
MO
It's not 93922 - 93922 is non-imaging study, and this report does not document ABI plus other physiologic study as required for 93922.
Oftentimes when an pseudoaneurysm is suspected after a heart cath they will do a duplex scan to evaluate for that and if so, it would be 93926. However, duplex scans require documentation of both color and spectral doppler along with images. "normal flow" probably indicates that they flipped on the color briefly, but there is no documentation to indicate that spectral doppler was also done.
I would code 76882, or send it back to the physician for clarification and/addendum if necessary.
 
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