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
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