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76856- 'when applicable’

  1. #1
    Default 76856- 'when applicable’
    Medical Coding Books
    I have a question about the statement of ‘when applicable' for a complete pelvic U/S? Can someone give me a good definition of what this is referring to? I have my understanding but I am putting together a presentation for some techs and I need to make sure I have my ducks in a row!

    Women: description and measurements of the uterus and adnexal structures, measurement of the endometrium, measurements of the bladder (when applicable), and descriptions of any pelvic pathology (eg, ovarian cysts, uterine leiomyomata, free pelvic fluid).

    Men: Evaluation and prostate and seminal vesicles to the extent that they are visualized transabdominally, evaluation and measurements of the bladder (when applicable), and descriptions of any pelvic pathology.

  2. #2
    Alexandria, LA
    Sometimes the patient has a foley catheter in place draining the bladder, which makes it not visible under ultrasound. In that case, evaluation of the bladder is "not applicable". However, your doctor must document that in the record.

  3. #3
    Great explanation…. Thanks!

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