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new coder needs help

  1. #1
    Default new coder needs help
    Medical Coding Books
    Need help with CPTs. Thanks.

    procedure: examination under anesthesia with CT of the abdomen and pelvis and pelvic ultrasound as well as Pap smear.

    The patient was taken to the CT scan suite and under IV sedation underwent CT of the abdomen and pelvis followed by pelvic ultrasound. We also obtained a Pap smear while the pateint was under IV sedation. Examination revealed her to have a pelvic mass extending to at least 6 cm above the umbilicus on the right side of the abdomen. This was consistent with fibroid uterus. Prelimiary report from radiology were also consistent with very large fibroid uterus. On vaginal speculum exam the cervix was very high in the pelvis but appreared grossly normal. There was a small amount of dark menstrual blood present in the cervical os. Pap smear was obtained. There were not palpable pelvic masses transvaginally but exam was limited by body habitus.

  2. Default
    You can code
    57410 pelvic exam under sedation which includes the pap.
    74176-26 CT of abdomen and pelvis
    76856-26 ultrasound of pelvis
    I am assuming you are billing for the physician and not the facility, so I added the -26 modifier.

  3. #3
    I am billing for the physician. Thanks.

  4. #4
    Maybe I am overlooking something but I do not see 76856-26 ultrasound of pelvis. This is a 'complete' code and has documentation requirements. Elements of this examination include a description and measurements of the uterus and adnexal structures, measurement of the endometrium, measurements of the bladder (when applicable) and a description of any pelvic pathology (eg, ovian cysts, uterine leiomyomata, free pelvic fluid).

    Does the report say hard copy images were taken?

    I also dont see the CT abd and pelvis on the report. Is this the only report?

  5. #5
    Default Ivus
    Does anyone bill for IVUS during the diagnostic/Internventional procedures ? Somehow I feel like I am double dipping when billing for the IVUS and the S&I code that goes with the procedure.
    ie: Vena Cava Filter

    Suggestions please ?

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