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76856 versus 76857

  1. #1
    Default 76856 versus 76857
    Medical Coding Books
    When billing for a pelvic US, does the report need to mention the bladder?

  2. Default
    76856 is for pelvic complete
    76857 is for pelvic limited/follow-up

    for the complete it has to mention all of the pelvic anatomy ie. for females, ovaries, uterus, bladder, etc.

    if the limited pelvic U/S 76857 is For the bladder, then yes it has to be commented on. If it is for the Uterus alone or follow up ovarian cyst, etc. it does not have to be mentioned

  3. #3
    Default
    Does everyone agree that when billing a complete pelvic US, bladder MUST be documented?

    Thanks.

  4. #4
    Default
    The reason I'm asking is because in CSI Navigator For: Diagnostic Radiology it states under
    76856/76857

    The following elements must be documented for a complete non-obstetric ultrasound exam of the female pelvis:
    -Description and measurements of the uterus and adnexal structures
    -Measurement of the endometrium
    -Measurement of the bladder (WHEN APPLICABLE)
    -Description of any pelvic pathology

  5. Default
    In my openion , 76856 and also for 76857 it might be when it is applicable; applicable, meaning, 'the physician decides so for some medical reason or medical necessiity to visualize the bladder and document.
    No harm in reporting it but not necessarily (not a mandatory) when there was not an applicability. It could still be paid for, in full.

    By the way, the pelvic US in female obviates Transvaginal; in transvaginal US procedures, the bladder is completely emptied before the start, for better visualization of the pelvic organs esp reproductive organs and appendages. Actually the normal bladder would not be visualized in doing so.
    That is why the term "when it is applicable " is inserted in the description of the code guidelines.

    So it is not mandatory to report or interpret unless it is medically needed

  6. #6
    Default
    Still having some controversy brewing over whether 76856 REQUIRES documentation of the bladder. The description of the code reads "when applicable".....how do you know when it's applicable?

    Thanks again!

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