What is the best way to report an encounter when both the kidney and bladder are imaged?

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Urology Times Journal, Vol 50 No 06, Volume 50, Issue 06

"For appropriate billing and coding, there are 2 important issues to be satisfied: medical necessity and documentation supporting the performance of the procedure," write Jonathan Rubenstein, MD, and Mark Painter.

I have an ultrasound machine that provides images. Can I use 76856 for a post-void residual (PVR) instead of code 51798? Also, we normally bill code 76705 for kidney ultrasounds and we use code 76857 for ultrasound of the bladder. What is the best way to report an encounter when both the kidney and bladder are imaged?

For appropriate billing and coding, there are 2 important issues to be satisfied: medical necessity and documentation supporting the performance of the procedure.

Regarding your first question, obtaining an image is secondary to the reason for the service based on patient condition and diagnostic needs. Remember that most payers have different rules for screening services than they have for services directed toward an existing problem. Medical necessity for a bladder scan will need to be clearly supported with chief complaint. The documentation will also need to describe the service provided and an interpretation of the image separately documented. Merely obtaining images does not satisfy the requirements to report CPT 76856 if the intent of the procedure was to obtain a PVR.CPT code 51798 should be reported to obtain a PVR whether using imaging or non-imaging modality.

For several questionable cases we have reviewed, the need for a PVR is supported by the chief complaint and the procedure note has included a full bladder scan image including pre- and post- void imaging and a full and separate report interpretation. In these cases, based on diagnosis restrictions and the chief complaint, we have recommended reporting code 51798.

The second question has been answered previously by the American Urological Association (AUA):

“You cannot bill for both a 76705 Ultrasound abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) and a 76857 Ultrasound, pelvic (nonobstetric), real time with image documentation, limited or follow-up (eg, for follicles) when each of these organs is evaluated. CPT code 76770 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation, complete should be billed if the clinical history suggests urinary tract pathology, and evaluation of both kidneys & bladder.”1

We agree with the AUA for coding in this regard as it follows CPT nomenclature and coding guidance.

We have heard there are some payers that will not allow for billing of code 76770 for this service and have requested the codes for kidney and bladder ultrasound to be reported separately when supported. If you have a payer requesting billing of services that do not agree with CPT nomenclature requirements, we strongly recommend that you obtain these instructions in writing.

Reference

1. Imaging radiological procedures. American Urological Association. Accessed June 2, 2022. https://bit.ly/3tcuGm8

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.