Question:

How is a grayscale ultrasound of a transplanted kidney, transplanted ureter, and native bladder reported?

Answer:

When a real-time ultrasound examination of a transplanted kidney, transplanted ureter, and native bladder without Doppler is performed, it is appropriate to report code 76775, Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real-time with image documentation; limited, because only one kidney is examined. However, if the remaining native kidney is also imaged, or was sought after but not seen due to atrophy or surgical removal, code 76770, Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real-time with image documentation; complete, is the appropriate code to report. Without duplex Doppler and spectral analysis of the transplanted kidney it is inappropriate to report code 76776, Ultrasound, transplanted kidney, real-time and duplex Doppler with image documentation. The CPT® codebook states: “A complete ultrasound examination of the retroperitoneum consists of real-time scans of the kidneys, abdominal aorta, common iliac artery origins, and inferior vena cava, including any demonstrated retroperitoneal abnormality. Alternatively, if clinical history suggests urinary tract pathology, complete evaluation of the kidneys and urinary bladder also comprises a complete retroperitoneal ultrasound. (Source: Clinical Examples in Radiology, Volume 8, Issue 3; Summer 2012)

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