Coding for abdominal, retroperitoneal, and pelvic ultrasounds are distinguished between complete and limited exams
The CPT® manual instructs that in order to report a complete exam all of the specified structures of the exam must be documented and, if a particular structure or organ cannot be visualized, the radiologist must indicate the reason. If there is no mention of the structure, or it is not indicated why it is missing, the exam must be changed to a limited. We have many exams where an ovary is not seen. The documentation is clear that it was attempted and not seen, but there is no reason given as to why. This is often the way these are dictated and, when speaking with our radiologists, it is very common for the reason an ovary is not seen to be unknown. Would documentation that scanning did not show the left (or right) ovary be sufficient to allow it to be counted toward a complete exam?
I would want some idea of why it could not be seen – if the doctor doesn’t know, then possible reasons could be given. Without some indication, I would code a limited.