Best coding tips for CPT code 76856 and 76830
Basics about Pelvic Ultrasound CPT code 76856
In Radiology, diagnosis related to pelvic region are very common to code. For example, for ovary cyst, pelvic pain, abdominal pain etc. are the common diagnosis for Pelvic exam in females. Mostly the ultrasound CPT code 76856 is used for pelvic region. This is the most frequently used Ultrasound CPT code in Radiology. Also, along with CPT code 76856, we will be mostly coding endovaginal CPT code 76830. Both these codes are coded together in most of the exam. But, medical coders should carefully read the documentation and then only code for Pelvic ultrasound (76856) and Endovaginal (76830) cpt codes. If the exam or the technique does not support any of these CPT codes, we should not assign these codes.
When to code CPT code 76856 &76830
There are two CPT codes for coding Pelvic Ultrasound, CPT code 76856 and 76857. Now, when all the pelvic organs including the uterus, adnexal structures, ovaries, endometrium, bladder along with a pelvic diagnosis are present, you can go ahead and code CPT code 76856 (complete exam). When only one organ or some of the region of pelvic is studied, we have to code a limited Pelvic ultrasound CPT code 76857. Hence, medical coders should read the medical report accurately to code between complete and limited ultrasound CPT code for pelvic region. And the Ultrasound CPT code 76830 is used when the endovaginal exam is performed. Below are the details description of all these CPT codes.
76856 – Pelvis, non-OB Ultrasound Complete Exam
76857- Pelvis, non-OB Ultrasound Limited Exam
76830- Pelvis, non-OB Endovaginal Exam
Points to remember while coding CPT code 76856
As you know the, their are OB and Non-OB CPT codes for Pelvic exam, hence do not get confuse with these codes. The Pelvic ultrasound OB Cpt code include codes 76801,76802, 76805, 76810 etc. While the Non-OB Pelvic CPT codes include 76856, 76857 and 76830.
Do not code the complete (76856) and limited (76857) exam CPT codes together. Both exam cannot be done together.
Do not code a complete exam CPT code 76856 for limited exam. This is called Upcoding, because your charging more by coding high dollar value CPT code.