Radiology Compliance Question of the Week

Radiology Question for the Week of April 4, 2022

We received an order from a referring physician that requested an ultrasound (US) thyroid for nodule assessment and a US soft tissue for a submental mass palpable on the exam. The facility coder believes that the facility should get two charges. The interpretation covers both areas in one report. It is my understanding that US head and neck (CPT® 76536) would cover both of these assessments. Am I correct? The evaluation is performed for two separate reasons, but the imaging is of the neck.

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Radiology Compliance Question of the Week

Radiology Question for the Week of June 28, 2021

I am confused about an answer regarding an ultrasound arthritis survey. It has been stated that when multiple joints are imaged ipsilaterally by ultrasound to report an unlisted code. However, if the physician completes 76881 bilaterally questioning arthritis, that would be 76881-50 or RT, LT, because it is not ipsilateral. Is that your understanding as well? Is there more information that you would have on the issue that you could direct me to?

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General Compliance Question of the Week

General Question for the Week of June 28, 2021

I have a question regarding the obstetrical (OB) ultrasound documentation guidelines. I know that the uterus and adnexa are required elements, but some of the providers feel that documenting an IUP should be sufficient for the 1st trimester (76801/76802). For codes 76805/76810, the guidelines state maternal adnexa should be reported “when visible.” So, do the doctors not have to document it when it is not visible?

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