New From CPT Assistant: Help with Trunk Ultrasound Coding
Posted on 24. Aug, 2009 by Editor in Hot Coding Topics
Do you know exactly what’s in the mediastinum? Your US coding depends on it.
Current payer policy on imaging guidance is especially strict, so you don’t want to miscode any ultrasound (US) services your ED physician provides. CPT Assistant has recently published a Q&A set that will help you get all the reimbursement you deserve for US service, without getting payback requests on improperly coded US.
Mediastinum Is Not Necessary for Chest US
CPT Assistant poses the question, “When reporting a chest US, is it necessary to include an examination of the mediastinum?”
No; however, if an examination of the mediastinum is indicated, it is included in chest US (76604, Ultrasound, chest [includes mediastinum], real time with image documentation), confirms Elijah Berg, MD, FACEP, CEO of MRSI, an ED coding and billing company in Woburn, Mass.
Impact: While the code descriptor does explicitly mention a mediastinum exam, you can report 76604 regardless of whether or not the physician documents examination of the area. (You cannot, however, report a mediastinum exam separately if the physician notes it during a chest US.)
AUDIO: Hospitalist Coding & Documentation Strategies That Get You Paid.
Where is it? According to Dorland’s Dictionary, the mediastinum is: “The mass of tissues and organs between the sternum anteriorly and the vertebral column posteriorly and from the thoracic inlet superiorly to the diaphragm inferiorly. It contains the heart and pericardium, the bases of the great vessels, the trachea and bronchi, esophagus, thymus, lymph nodes, thoracic duct, phrenic and vagus nerves, and other structures and tissues.”
Use These CPT Designations on Soft-Tissue US …
CPT Assistant also poses the question, “Which code represents a US of a palpable soft-tissue mass?” You should code this based on the location of the abnormality, CPT says:
• neck: 76536 (Ultrasound, soft tissues...
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