Monday, September 12, 2016

Procedure Code 76770, 76775, 76776 - retroperitoneal ultrasound

Procedure Code AND Description

76770 - Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete - Average fee amount $100 - $130

76775 - Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited

76776 - Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation


For the evaluation of a transplanted kidney with duplex report CPT code 76776, without duplex CPT code 76775. 76776 Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation

Examples of Claim Adjudication Scenarios: Preventive vs. Diagnostic:

1. Member is a 65 year old male with previous history of smoking and is scheduled for an abdominal aortic aneurysm (AAA) by ultrasonography. Provider bills Procedure code 76770 with and ICD.10 code Z87.891. This would be considered a preventive service with no cost to the member.

2. Member is a 60 year old male with no previous history of smoking but with abdominal symptoms requiring an abdominal ultrasound. Provider bills Procedure code 76775 and ICD.10 code R10.9 or R10.0. The procedure code billed is used for preventive services but the ICD.10 code is not and therefore based on the age of the member (or insured) and the diagnosis code, this would be considered a diagnostic procedure and subject to the member’s benefit plan.

3. Member is a 73 year old male with previous history of smoking and is scheduled for an abdominal aortic aneurysm (AAA) by ultrasonography. Provider bills Procedure  code 76770 with and ICD.10 code Z87.891. Member or insured, also scheduled for an ultrasound of the carotid arteries. Provider bills Procedure code 93880 and ICD.10 code R55. No cost share would be taken on Procedure code 76770 as this is considered a preventive service within the recommended preventive service criteria but cost share would be taken on Procedure code 93880 as this is a non-preventive service.

Indications and Limitations of Coverage and/or Medical Necessity


Retroperitoneal ultrasound studies represent the ultrasonic imaging of retroperitoneal organs for the diagnosis and management of abnormalities that occur in the retroperitoneum.

A complete study visualizes all the structures or organs within the anatomic description of that study. A limited study involves a single quadrant or a single diagnostic problem or an evaluation of an organ of interest.

Retroperitoneal ultrasonography may be considered reasonable and necessary for the diagnosis and treatment of the following areas:

1. Pancreas

2. Abdominal aorta - Ultrasound is accurate for aortic measurement and may be used to follow patients with aneurysms.

3. Inferior vena cava- Ultrasound is useful in detection of invasion by adjacent tumors and identification of obstruction levels.

4. Kidneys, ureter, and bladder:


a) Kidneys-

i) To evaluate obstruction in symptomatic patients and for guidance of percutaneous nephrostomy tubes. May also confirm scarred or small kidneys in chronic renal cortical disease (but may be of no use in detecting early or mild cortical disorders or to categorize specific types of cortical diseases).

ii) May be useful in detecting and following renal cysts and localizing solid masses.

iii) May be useful as a primary diagnostic tool in patients with hematuria.


b) Ureter- Ureters are usually not well visualized by ultrasound, especially in their mid-portions; ultrasound may rarely be helpful to confirm the presence of dilatation, filling defects or a mass, in its most proximal or distal portions. Ultrasound has no role in vesicle ureteral reflux.

c) Bladder- Tumors of the bladder are most efficiently followed by cystoscopy and urography. However, ultrasound is useful in following intraluminal bladder tumor with or without extraluminal extension, including evaluation of bladder wall thickness and irregularity.


5. Renal transplants- Ultrasound is indicated to detect urinary obstruction, fluid collection, and complications of renal transplants and is considered a primary tool in this endeavor. The presence or absence of signs and symptoms dictate utilization frequency of this modality for renal transplants.

6. Adenopathy- CT is far more accurate than ultrasound in detecting and delineating adenopathy. Ultrasound in this instance should be considered secondary and rarely utilized in the detection or follow up of nodal disease.

7. Prostate- Evaluation of the prostate is primarily done transrectally by ultrasound.

8. Adrenal Gland- Ultrasound is of little value since CT scan is considered more accurate.

9. Organs located in the retroperitoneal region-Ultrasound may be helpful in evaluation of wounds, contusions, and lacerations of organs located in the retroperitoneal region.


Examples of Claim Adjudication Scenarios: Preventive vs. Diagnostic:

1. Member is a 65 year old male with previous history of smoking and is scheduled for an abdominal aortic aneurysm (AAA) by ultrasonography. Provider bills Procedure code 76770 with and ICD.10 code Z87.891. This would be considered a preventive service with no cost to the member.

2. Member is a 60 year old male with no previous history of smoking but with abdominal symptoms requiring an abdominal ultrasound. Provider bills Procedure code 76775 and ICD.10 code R10.9 or R10.0. The procedure code billed is used for preventive services but the ICD.10 code is not and therefore based on the age of the member (or insured) and the diagnosis code, this would be considered a diagnostic procedure and subject to the member’s benefit plan.

3. Member is a 73 year old male with previous history of smoking and is scheduled for an abdominal aortic aneurysm (AAA) by ultrasonography. Provider bills Procedure code 76770 with and ICD.10 code Z87.891. Member or insured, also scheduled for an ultrasound of the carotid arteries. Provider bills Procedure code 93880 and ICD.10 code R55. No cost share would be taken on Procedure code 76770 as this is considered a preventive service within the recommended preventive service criteria but cost share would be taken on Procedure code 93880 as this is a non-preventive service.


Billing and Coding Guidelines


• Aetna will cover a one-time ultrasound screening for AAA for men 65 code 76770 – complete retroperitoneal ultrasound or Procedure code 76775 – limited retroperitoneal ultrasound, as appropriate for the reporting of this service. Payment rates are not publicly available and will depend upon the contract each provider has negotiated with Aetna.

• Cigna will cover a one-time ultrasound screening for AAA for men age 65 - 75 who have ever smoked, male nonsmokers nearing age 65 with a family history of AAA, and female smokers age 70 or older with a family history of AAA. These coverage criteria only apply for those members who have coverage for preventive health services. Cigna’s policy also references the limited and complete retroperitoneal ultrasound codes. Payment rates are proprietary and variable as above.


• Several of the Blue Cross Blue Shield companies advise members determined by their physicians to be at risk for AAA to receive screening for AAA, but they note that this service may not be covered under all plans. In all instances, it is advisable for providers to contact the private insurance companies prior to providing the AAA screening to verify coverage
for their individual patients.


• A kidney can be evaluated as a part of a larger exam, or by itself. If it is part of a larger exam, use the Procedure code 76770 - Ultrasound, retroperitoneal e.g. renal, aorta, nodes, real time with image documentation; complete. According to Procedure a complete ultrasound examination of the retroperitoneum consists of B mode scans of kidneys, abdominal aorta, common iliac artery origins, and inferior vena cava, including any demonstrated retroperitoneal abnormality. Alternatively, if clinical history suggests urinary tract pathology, complete evaluation of the kidneys and urinary bladder also comprises a complete retroperitoneal ultrasound. Otherwise, a limited exam is reported with Procedure code 76775. A limited study evaluates a single area or organ of interest.


Procedure Code Descriptor Global Payment Professional Payment Technical

Payment APC Code APC Payment 76770 Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; complete. $132.39‡ $36.08 $96.31‡ 0266 $96.31


A complete ultrasound examination of the retroperitoneum (76770) consists of real time scans of the kidneys, abdominal aorta, common iliac artery origins, and inferior vena cava, including any demonstrated retroperitoneal abnormality.” Alternatively, if clinical history suggests urinary tract pathology, complete evaluation of the kidneys and urinary bladder also comprises a complete retroperitoneal ultrasound.

The documentation for diagnostic ultrasounds for a “complete” exam should contain a description of all required elements or explain as to why they could not be visualized. If the exam entails anything less than the above mentioned regions or does not explain why they could not be visualized, the corresponding limited ultrasound code would be reported. A “limited” study includes only a single quadrant or a single diagnostic issue.

This is why documentation is very important for these studies. If the documentation does not meet Procedure code guidelines for a retroperitoneal ultrasound (76770) by leaving out a comment on one or two of the required elements it means reporting 76775 for the limited. If billing globally this can be $20 less in reimbursement. A checklist may be one way to be sure all areas are covered for each ultrasound


Abdomen and Retroperitoneum Ultrasounds  Is a particular imaging study a limited or complete procedure?

There are four ultrasound codes that can be challenging. Choosing an incorrect code could have an impact on reimbursement. The four codes are:

* 76700 - Ultrasound, abdominal, real time with image documentation; complete

* 76705 - ..........limited (eg, single organ, quadrant, follow-up)

* 76770 - Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete

* 76775 - ..........limited

Per CPT, “A complete ultrasound examination of the abdomen (76700) consists of real time scans of the liver, gallbladder, common bile duct, pancreas, spleen, kidneys, and the upper abdominal aorta and inferior vena cava including any demonstrated abdominal abnormality.”

Per CPT, “A complete ultrasound examination of the retroperitoneum (76770) consists of real time scans of the kidneys, abdominal aorta, common iliac artery origins, and inferior vena cava, including any demonstrated retroperitoneal abnormality.” Alternatively, if clinical history suggests urinary tract pathology, complete evaluation of the kidneys and urinary bladder also comprises a complete retroperitoneal ultrasound.

The documentation for diagnostic ultrasounds for a “complete” exam should contain a description of all required elements or explain as to why they could not be visualized. If the exam entails anything less than the above mentioned regions or does not explain why they could not be visualized, the corresponding limited ultrasound code would be reported. A “limited” study includes only a single quadrant or a single diagnostic issue.

This is why documentation is very important for these studies. If the documentation does not meet CPT guidelines for a retroperitoneal ultrasound (76770) by leaving out a comment on one or two of the required elements it means reporting 76775 for the limited. If billing globally this can be $20 less in reimbursement. A checklist may be one way to be sure all areas are covered for each ultrasound.


Payment for Multiple Imaging Composite APCs

Effective for services furnished on or after January 1, 2009, multiple imaging procedures performed during a single session using the same imaging modality are paid by applying a composite APC payment methodology. The services are paid with one composite APC payment each time a hospital bills for second and subsequent imaging procedures described by the HCPCS codes in one imaging family on a single date of service. The I/OCE logic determines the assignment of the composite APCs for payment. Prior to January 1, 2009, hospitals received a full APC payment for each imaging service on a claim, regardless of how many procedures were performed during a single session.

The composite APC payment methodology for multiple imaging services utilizes three imaging families (Ultrasound, CT and CTA, and MRI and MRA) and five composite APCs: APC 8004 (Ultrasound Composite); APC 8005 (CT and CTA without Contrast Composite); APC 8006 (CT and CTA with Contrast Composite); APC 8007 (MRI and MRA without Contrast Composite); and APC 8008 (MRI and MRA with Contrast Composite). When a procedure is performed with contrast during the same session as a procedure without contrast, and the two procedures are within the same family, the “with contrast” composite APC (either APC 8006 or 8008) is assigned.

CMS has updated the list of specified HCPCS codes within the three imaging families and five composite APCs to reflect HCPCS coding changes. Specifically, CMS added CPT code 74176 (Computed tomography, abdomen and pelvis; without contrast material), CPT code 74177 (Computed tomography, abdomen and pelvis; with contrast material(s)), and CPT code 74178 (Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions) to the CT and CTA family. These codes are new for CY 2011. CMS also added HCPCS codes C8931 (Magnetic resonance angiography with contrast, spinal canal and contents), C8932 (Magnetic resonance angiography without contrast, spinal canal and contents), C8933 (Magnetic resonance angiography without contrast followed by with contrast, spinal canal and contents), C8934 (Magnetic resonance angiography with contrast, upper extremity), C8935 (Magnetic resonance angiography without contrast, upper extremity), and C8936 (Magnetic resonance angiography without contrast followed by with contrast, upper extremity), to the MRI and MRA family. These codes were recognized for OPPS payment in the October 2010 OPPS Update (Transmittal 2050, Change Request 7117, dated September 17, 2010). The specified HCPCS codes within the three imaging families and five composite APCs for CY 2011 are provided below

Table 1 – The Specified HCPCS Codes Within the Three Imaging Families and Five Composite APCs for CY 2011

Family 1 – Ultrasound


CY 2011 APC 8004 (Ultrasound Composite)
76604 Us exam, chest
76700 Us exam, abdom, complete
76705 Echo exam of abdomen
76770 Us exam abdo back wall, comp
76775 Us exam abdo back wall, lim
76776 Us exam k transpl w/Doppler
76831 Echo exam, uterus
76856 Us exam, pelvic, complete
76870 Us exam, scrotum
76857 Us exam, pelvic, limited

 

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