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For pelvic ultrasound, if a required element cannot be visualized, the reason for non-visualization must be given or the limited study code must be reported

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Q.

In seminars, we have been told that when the radiologist reads a pelvic ultrasound and, if all elements of the code cannot be visualized, the radiologist must document in the report why the element cannot be visualized in order for us to code it as complete. Can you tell me where this instruction is documented from an authoritative source so that the radiologist will understand why they need to document this information as they do not believe this? 

A.

If you have a CPT® book, it is in the general ultrasound guidelines, and it also says it in the OB ultrasound guidelines (it is not just a rule for OB ultrasounds). 

In addition, this is from the ACR Ultrasound Coding User’s Guide: 

“Documentation of all elements that constitute a complete examination must be given. To report a complete examination, all of the elements must be described in the procedure report. If a required element cannot be visualized, the reason for non-visualization [e.g., obscured by bowel gas] must be given or the limited study code must be reported.:

To demonstrate for your providers that this isn’t a new rule, the Summer 2004 issue of Clinical Examples in Radiology, co-published by the American Medical Association (AMA) and the American College of Radiology (ACR) included a case sample of an OB ultrasound. The discussion included the following:

“Since this is a second trimester pregnancy it is inappropriate to use the first trimester codes 76801 and 76802. Of the post-first trimester codes, it would be inappropriate to code 76805 or 76810 since each and every element required for these procedures (as noted in the Obstetrical introductory comments in the CPT® manual) was not enumerated or commented upon in the report.”

“Coding Tips

In order to use one of the various levels of codes, the report should document the results of the evaluation of each element required or the reason for non-visualization.”