April 30, 2003

ACR Radiology Coding Source™ March-April 2003 Q and A

Q: If a vascular study (with or without color doppler) is performed in conjunction with ultrasound of the liver, is it appropriate to report both CPT code 76705 (Abdominal ultrasound, limited) and CPT code 93975 (Duplex scan of arterial inflow and venous outflow of abdominal, pelvic and/or retroperitoneal organs; complete study)?

A: Yes, if an ultrasound of the liver is performed, and there is a clinical need for further evaluation by duplex scanning, then it is appropriate to code for both 76705 and 93975.

A vascular study (with or without color flow) may be reported in addition to ultrasound studies when it is clinically indicated (medically necessary). The radiology codes for ultrasound (e.g. abdomen, retroperitoneal, etc.) generally represent two-dimensional (gray-scale) imaging. For example, CPT-4 code 76700 includes gray-scale real-time or static images of the entire abdomen from the diaphragm to the level of the umbilicus. If the study includes anything less than the all-inclusive code 76700, then the limited code 76705 should be billed.

Sometimes a vascular study is added to the basic gray-scale study when enhancement of suspect areas or more detailed analysis is needed. CPT code 93975 describes evaluation of arterial inflow and venous outflow of abdomen, retroperitoneum, scrotal contents and/or pelvic organs. This code can be used whether single or multiple organs are studied. It is a "complete" procedure in that all major vessels supplying blood flow (inflow and outflow, with or without color flow mapping) to the organ are evaluated. If the study is only a partial evaluation, then the limited code (93976) is billed. Therefore, in cases where it is necessary to perform a vascular study in conjunction with ultrasound of an organ, it would be appropriate to report the vascular study separately.

In order to code an abdominal duplex study, true vascular analysis needs to be performed. Abdominal duplex should not be coded when color is just turned on to determine if a structure is vascular (e.g. distinguishing hepatic artery from the common bile duct).

Note that since January 1997, Medicare Correct Coding Initiative (CCI) edits have been in place for the vascular study codes (93975/93976) when used in conjunction with the pelvic ultrasound codes (76856/76857). Medicare considers these pairs to be mutually exclusive—that is, they should not be performed by the same physician, for the same patient, on the same date of service. The code pair edits do list a modifier indicator of "1" with the vascular study codes (939751,939761); therefore, it would be appropriate to submit these codes together with a modifier attached to the vascular study code (e.g. 93975–59 or 93976–59). For example, a patient comes in with pelvic pain, and the US of the pelvis demonstrates an enlarged ovary. The differential diagnosis includes torsion of the ovary. A vascular study is requested to establish the arterial inflow and venous drainage of the ovary and determine torsion or infarction. In this scenario, it would be appropriate to code 76856 for the pelvic ultrasound and 93976-59 for the limited vascular study of the ovary.

Q: Is it appropriate to use one of the new urinary catheterization codes (51701, 51702 or 51703) in conjunction with the nuclear medicine ureteral reflux study code (78740)?

A: Yes, it is appropriate to use code 51701, 51702, or 51703 in conjunction with the nuclear medicine code 78740 [Ureteral reflux study (radiopharmaceutical voiding cystogram)] when a physician performs the catheterization.

Urinary catheterization, as described by the newly created 2003 CPT® codes 51701, 51702, and 51703, is not part of a ureteral reflux study. These new codes replace urethra catheterization codes 53670 (simple) and 53675 (complicated) and HCPCS code G0002 [Office procedure, insertion of temporary indwelling catheter, Foley type (separate procedure)]. The codes are broken down into three types of bladder catheterization procedures: insertion of a non-indwelling catheter (e.g. for residual urine); insertion of a temporary indwelling catheter, simple (e.g. a Foley catheter); and insertion of an indwelling catheter, complicated (e.g. possible complications such as altered anatomy, fractured catheter/balloon). These urinary catheterization procedures would be performed prior to a radiopharmaceutical voiding cystogram (78740). The radiopharmaceutical voiding cystogram (ureteral reflux study) is a separate and distinct study and is performed for the detection of vesicoureteral reflux with dynamic imaging during filling and emptying of the urinary bladder.

Note: it would not be appropriate to code 51701, 51702, or 51703 if urinary catheterization is performed as a small component of a larger surgical procedure. Note also that urinary catheterization should only be coded separately if it is done by a physician-- not by a nurse or technologist.

Virtual Colonoscopy Clarification:

As a follow-up to the January/February Q&A on coding for virtual colonoscopy, note that if only a "fly through" study is performed and interpreted, and all of the hundreds of axial images are not interpreted, then the unlisted CT code (76497 Unlisted computed tomography procedure) should be used to describe the virtual colonoscopy study.

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