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Ultrasound abdominal aorta

  1. #1
    Red face Ultrasound abdominal aorta
    Medical Coding Books
    Merry Christmas to all!
    I have a question regarding the proper documentation of cpt 93978 and 93979 ( duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts, complete study and 93979 (same scan but limited study) Our referring doctors usually order an ultrasound aorta as a screening for abdominal aortic aneurysm. Documentation of the report is normally as what follows:
    "Sonographic eval of the aorta and adjacent structures was performed using a curvilinear sector trasnducer. Color and pulsed Dopper evaluation was performed. The course and caliber of the abdominal aorta appears normal. The maximal dimension of the aorta measures 1.3 cm in size. There are no adjacent abnormalities. The lumen appears patent without significant plaques or stenoses. Pulsed Doppler waveforms appeared normal."
    Would the above documentation support cpt 93978 as a complete study. The radiologist does not mention the inferior vena cava by name, and I am questioning whether he definitely has to mention the inferior vena cava and the iliac vessels to be justified in coding a 93978?

    What constitutes a complete exam regarding this issue? I would appreciate any and all help you can offer on this subject.

    Claudia K, CPC

  2. #2
    Our Rads go by what the ACR uses in their definition and it states in the exam word for word that ALL have been viewed when doing the complete... anything less and we use the 93979:

    93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study

    93979 unilateral or limited study

    Happy Holidays to you too!!!! Hope this helps!

  3. #3
    Default duplex scan aorta
    Thanks so much for your input!
    ClaudiaK, CPC

  4. #4
    Fort Worth Texas
    I also agree with jgf. They have to document everything. They also have to say color and pulsed doppler or something similar to get credit.

    Also when it says specifically that they are "screening for an abdominal aortic aneurysm" and we know they are a Medicare patient, we have been told to use G0389 instead of the 93978.

  5. #5
    Default duplex scan aorta
    Thanks so much for the in fo. Have a Happy New Year!


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