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CPT Code 76856 complete Pelvic evaluation

  1. Unhappy CPT Code 76856 complete Pelvic evaluation
    Medical Coding Books
    I am new to radiolgy procedures. Can CPT code 76856 be used for the following exam?

    Exam: Pelvic US complete

    Reason for exam: Pelvic Pain

    Findings:
    The uterus is not identified, the patient is status post hysterectomy. Neither ovary is identified. There are bowel loops in the pelvis. No discrete mass or free fluid seen in the visulaized pelvis.
    Impression: Satus post hysterectomy. Ovaries are not identified. No discrete mass or free fluid seen.

    Thank you

  2. #2
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    Tacoma, WA
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    Quote Originally Posted by tvmedical@earthlink.net View Post
    I am new to radiolgy procedures. Can CPT code 76856 be used for the following exam?

    Exam: Pelvic US complete

    Reason for exam: Pelvic Pain

    Findings:
    The uterus is not identified, the patient is status post hysterectomy. Neither ovary is identified. There are bowel loops in the pelvis. No discrete mass or free fluid seen in the visulaized pelvis.
    Impression: Satus post hysterectomy. Ovaries are not identified. No discrete mass or free fluid seen.

    Thank you
    No, not enough elements to qualify for 76856. "Elements of this exam include evaluation and measurements of the uterus and adnexal structures, measurement of the endometrium, measurement of the bladder (when applicable), and a description of any pelvic pathology (eg, ovarian cysts, uterine leiomyomata, free pelvic fluid)." "Code 76857 represents a focused examination limited to the assessment of one or more elements listed in code 76856.." This documentation qualifies for 76857 for pelvic pain post-hysterectomy.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. Question CPT Code 76856 complete Pelvic evaluation
    Thank you so much for your feedback.

    However, can CPT code 76856 (US Pelvic, complete) be used on patients who have had radical hysterectomies? If there is no uterus, no endometrium, and no cervix, the physician cannot document measurements or descritptions regarding the organs listed; should I always use CPT code 76857 (pelvic limited exam) for hysterectomy cases? I'm sorry to bombard you with so many questions, but I am new to Radiolgy coding and I don't want to submit an incorrect code.

    Thanks again.

  4. Default
    Published in Radiology Coding Alert, August 2007

    Question: When coding a non-obstetric pelvis ultrasound (US) for a patient who has had a hysterectomy, should I report a limited exam or complete exam?
    Missouri Subscriber
    Answer: For females, complete nonobstetric ultrasound (76856, Ultrasound, pelvic [nonobstetric], real time with image documentation; complete) includes the following:

    uterus and adnexal structure description and measurement

    endometrium measurement

    bladder measurement (when applicable)

    pelvic pathology description.

    As long as the doctor documents each of the required elements or notes the reason he could not [...]

  5. #5
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    Tacoma, WA
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    Quote Originally Posted by tvmedical@earthlink.net View Post
    Thank you so much for your feedback.

    However, can CPT code 76856 (US Pelvic, complete) be used on patients who have had radical hysterectomies? If there is no uterus, no endometrium, and no cervix, the physician cannot document measurements or descritptions regarding the organs listed; should I always use CPT code 76857 (pelvic limited exam) for hysterectomy cases? I'm sorry to bombard you with so many questions, but I am new to Radiolgy coding and I don't want to submit an incorrect code.

    Thanks again.
    If the documentation had included more information regarding the pelvic cavity, (eg, measurements of the bladder, or any more detail), it could have been billed as complete 76856. The problem is that the documentation you presented did not cover a complete exam, even without the uterus. If more had been documented about the remaining structures in the pelvic cavity, then it could have been complete.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  6. Smile CPT Code 76856 complete Pelvic evaluation
    Thanks Arlene.

    I failed to inform you that there was a urinary bladder report; it was reported on a different page. Our radiologists generates a seperate report for Urinary Bladder Ultra Sounds; however, it's all coded using either 76856 or 76857. The complete report reads as follows:

    Exam: Pelvic US complete

    Reason for exam: Pelvic Pain

    Findings:
    The uterus is not identified, the patient is status post hysterectomy. Neither ovary is identified. There are bowel loops in the pelvis. No discrete mass or free fluid seen in the visulaized pelvis.
    Impression: Satus post hysterectomy. Ovaries are not identified. No discrete mass or free fluid seen.

    Findings:

    Urinary bladder is moderately full with a volume of 173cc. There are mobile internal echoes within the urinary bladder. There is no bladder wall thickening. There was no sinificant post void residual.

    Ipression:
    Mobile Internal echoes within the bladder, may be debris or hemorrhage, correlate clinically for cystitis.

    Does this document qualify for a 76865?

    Thank you so much for your input.
    Last edited by tviruet; 12-09-2011 at 11:28 AM. Reason: Forgot to ask one question.

  7. #7
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    Alexandria, LA
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    The doctor says "Neither ovary is identified." but he doesn't say why the ovaries were not identified - have they been removed (hysterectomy AND oophorectomy)? or obscured by bowel gas? or ?
    If one of the required elements can't be seen they must document why or the element cannot be coded.
    Because of that, you must code 76857 for this report.

  8. Talking CPT Code 76856 complete Pelvic evaluation
    Thank you for giving me further insight. You guys have been very helpful!!

  9. #9
    Default elements required for CPT 76856(male)
    Please give me the correct cpt code for the below

    Inguinoscrotal Ultrasonography
    Right testis is of normal position , size and shape, with smooth outline, showing normal homogenous
    echo pattern. No focal testicular lesions detected .
    RT. Testis = 42 x 23 mm in dimensions.
    Left testis present in proximal portion of left inguinal canal , it is of small size with inhomogenous
    texture calcified epididmis , no focal lesion
    LT. Testis = 21x7.3 mm in dimensions.
    Right epididymis is of normal size and texture with no focal lesions.
    Minimal right hydrocele.
    No hernial sacs.
    Conclusions
    Left undescended testis , seen in inguinal canal.

  10. Default us non ob
    PELVIC ULTRASOUND

    EXAM DATE: 1/2/2018 04:45 PM.

    CLINICAL HISTORY: ENDOMETRITIS.

    COMPARISON: 12/31/2017 pelvic ultrasound.

    TECHNIQUE: Realtime transabdominal pelvic scan performed to identify the uterus and adnexa and as an overview of other pelvic structures, with static image documentation.

    FINDINGS:
    Uterus: 14.7 x 8.6 x 8.2 cm, volume 539.05 cc. Anteverted position. Heterogeneous echotexture. No fibroids.
    Masses: None.
    Endometrium: 38 mm. Heterogeneous with numerous punctate hyperechoic foci and scattered flow.
    Cervix: Unremarkable.

    Right Ovary: 3.0 x 2.5 x 2.1 cm, volume 8.2 cc. Normal echotexture and blood flow.
    Left Ovary: Not seen

    Free Fluid: None.

    Other: None.

    IMPRESSION:
    1. Enlarged, postpartum uterus.
    2. The endometrium remains heterogeneous and markedly thickened with scattered areas of flow suggesting retained products of conception and/or blood products. Endometritis not excluded.
    3. Nonvisualization of left ovary. The right ovary is normal.
    4. No free fluid within the pelvis.


    how will u code that scenario.....cpt reason

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