Coding for scrotal ultrasound including bilateral inguinal hernia evaluation
I am looking for guidance for an upcoming exam. If an order for an US scrotum also includes bilateral inguinal hernia evaluation, do these images fall under the scrotal CPT® code of 76870? If not, would we then perform the scrotum as well as a groin ultrasound (CPT code 76882)? If both groins are to be evaluated, would two groin orders be needed, or is there a complete groin code option that would include both sides (CPT code 76880)?
You would assign CPT codes 76870 and 76882 x 2 (or 76882–50, or 76882–LT and 76882–RT, depending on payor preference). Since the order states US scrotal and include bilateral inguinal hernia evaluation, we would feel confident stating you do not need another order. If you do want a specific order for the inguinal hernia portion, you would not necessarily need two separate orders as long as it says bilateral.
The codes and full descriptions are:
76870 Ultrasound, scrotum and contents
76882 Ultrasound, limited, joint or other nonvascular extremity structure(s) (e.g. joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft-tissue structure[s], or soft-tissue mass[es]), real-time with image documentation