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Pelvic ultrasound - complete vs limited

  1. #1
    Default Pelvic ultrasound - complete vs limited
    Medical Coding Books
    The techs are taking measurements both transabdominally and transvaginally but the rads are putting them in the transvag report - they explained to me that the transvag measurements are more accurate. Would you code reports like this one as 76856 and 76830 (both transabdominal and transvaginal were ordered by the referring doc)

    Transabdominal examination shows normal appearing bladder. The uterus is unremarkable. The ovaries are not demonstrated on transabdominal examination.
    The transvaginal examination shows normal appearing uterus measuring 7.4 x 2.4 x 3.9 cm with a volume of 37 cc. Homogeneous uniform endometrium is noted measuring 2.6 mm in its greatest thickness. Small benign Nabothian cysts are seen at the cervix. The ovaries are noted demonstrated on transvaginal examination. No evidence of pelvic mass or fluid collections are seen.
    Thank you

  2. Default
    I work for a Radiologist group and we always would code both CPT if they clearly document in their dictation that they did both trans-ab and trans-vag.. Based on your report, they dictated both so you should be fine coding both.

  3. Default
    I too agree with Heidi.If both transabdominal and transvaginal imaging are documented in the report,then 76856 as well as 76830 should be coded

    Prabha CPC

  4. #4
    I agree too, BOTH need to be coded if both are dictated. Remember, you only code for what is dictated!

    Amber, CPC

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