Coding for pre- and post-void bladder ultrasound

Q.

Can you tell me the correct CPT^® code for a bladder pre- and post-void with ultrasound imaging?

A.

The correct CPT code for a bladder pre- and post-void with ultrasound would be limited pelvis, CPT code 76857.

Guidelines in the CPT book tell us code 76857 should be reported for a bladder ultrasound. Code 51798 should only be reported if a bladder volume study or post-void residual measurement is obtained without imaging.

And Clinical Examples in Radiology, co-published by the AMA and ACR included the following in a test case discussion:

“When a bladder-only study (male or female) with and without post-void residual is ordered and performed, code 76857, Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles), should be reported” (Clinical Examples in Radiology Volume 9, Issue 3; Summer 2013).

The code and full description are as follows:

76857 Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles)