Coding for complete abdominal ultrasound, for a limited procedure, for US-guided paracentesis and for identifying ascites

Q.

If a provider performed an ultrasound of the abdomen to evaluate for ascites, would that be described by an unlisted procedure code (i.e., UPC) or CPT^® code 76705? Imaging was performed of the entire abdomen but documentation did not contain all of the elements required to support assignment of CPT code 76700.

A.

In this example, the exam is defined by CPT code 76705. If the abdomen is evaluated by ultrasound but the elements required for complete abdominal ultrasound (CPT code 76700) are not documented, then limited CPT code 76705 would be reported. If the same provider went on to do a paracentesis at the same session using ultrasound guidance, then only CPT code 49083 would be reported. The original ultrasound localization of ascites would be included in CPT code 49083.