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Field Guide to Physician Coding 3rd Edition


Forum Discussion Areas > Ask Us a Question > need CPT® code and modifier
  need CPT® code and modifier
need CPT® code and modifier
Sep 2 2012, 9:30 PM
GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable. IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified. Identify the correct CPT-4 procedure (ICPT) code(s) for the above scenario

re: need CPT® code and modifier
Sep 3 2012, 9:28 AM
A complete abdominal ultrasound (76700) would consist of real time scans of the: liver, gall bladder, common bile duct, pancreas, spleen, kidneys, upper abdominal aorta and inferior vena cava including any demonstrated abdominal abnormality (this was not done). The most common modifier used with ultrasound is probably the -26 Professional Component modifier. Ultrasound, abdominal, real time with image documentation limited (e.g., single organ, quadrant, follow-up) 76705 (-26).


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