Performed at VAC or Portable

Limited vs Complete US Studies: Almost all IR portable US studies should be properly considered as “limited” unless indicated otherwise.

• Complete studies evaluate specific major structures within the anatomic description. Complete US of the abdomen (76700) includes the liver, gall bladder, common bile duct, pancreas, spleen, kidneys, and the upper abdominal aorta and IVC.
• Limited studies examines only a single quadrant, a single diagnostic problem or is used for follow-up examination.
• US codes generally represent gray-scale imaging.
• A vascular study (with or without color flow) may be reported in addition to ultrasound studies when it is clinically indicated (medically necessary). 

Ultrasound Procedure Documentation

​There are three specific requirements for reporting: 1. Written report, 2. Indication, and 3. Interpretation.
 
CPT requires all diagnostic and guidance ultrasound studies to have permanently recorded images. It does not indicate image documentation specifications, e.g. how many images, what views, what medium is utilized for storage or where images are stored. 

Code	Ultrasound Study
76882	Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific
93971	Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study
76536	Head and Neck (soft tissues): Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation
76604	Chest wall, Upper back. Ultrasound, chest (includes mediastinum), real time with image documentation
76642	Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited
76645	Pelvic wall, buttock, penis, perineum
76857	Ultrasound, pelvic (non-obstetric), real time with image documentation; limited or follow-up (eg, for follicles)
76512	Ocular Ultrasound: Ophthalmic ultrasound, diagnostic; B-scan (with or without superimposed non-quantitative A-scan)
76705	Abdominal Limited Ultrasound (e.g., single organ such as GB, quadrant, follow-up, Lower Back, Abdominal Wall)
76775	Retroperitoneal Limited Ultrasound (e.g., renal, aorta, nodes)
76870	Scrotal Ultrasound
93971	Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study
76705	Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant, follow-up)
76775	Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited
93926	Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study
93931	Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study
93971	Duplex scan of aorta, IVC, iliac vasculature, or bypass grafts; unilateral or limited
93976	Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow)
93979	Duplex scan of extracranial arteries; unilateral or limited study
93976	Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; Limited

 

modifier 59

​Distinct Procedural Service: can be used to report procedures that are distinct but have the same code. (e.g. multiple venous malformations in both the right upper and lower extremities). Code 76880 (US extremity, nonvascular, real time with image documentation) can be used twice, with a -59 modifier.