by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC

Question:

Patient sent to our facility for pelvis and transvaginal ultrasound. Our standard protocol is to do the ultrasound with color Doppler and obtain spectral waveform ovarian arterial and venous flow.

Is 93976 appropriate in addition to the ultrasounds? We did not have a provider order but it is our standard.

Indication menorrhagia

Technique Routine pelvic ultrasound protocol. Transabdominal evaluation of general pelvic anatomy and uterine size. Transvaginal evaluation of the endometrium, myometrial detail and evalulation of ovaries and adnexa with doppler

FINDINGS: bladder is not adequately prepped for proper transabdominal examination of the pelvis

UTERUS: measures 7.8 x 3.6 x 5.4 cm. The endometrium measures 0.7 cm. No focal myometrial abnormality

RIGHT OVARY: measures 2.8 x 2.0 x 2.1 cm. No right adnexal or right ovarian mass. No abnormal or non physiologic cyst. Blood flow is demonstrated by Doppler

LEFT OVARY: measures 2.9 x 2.2 x 2.9 cm. No left adnexal or left ovarian mass. No abnormal or non physiologic cyst. Blood flow is demonstrated by Doppler

PERITONEUM: No ascites or mass

IMPRESSION: Normal pelvis

Answer:

You do not state in your question what the “facility” is. Are you assigning codes for the hospital or for the physician (Pro fee billing)?

Coding based upon “routines” or “protocols” is not recommended as the true medical necessity for a study may be in question. Remember, a technologist (i.e. a non-physician, non-other qualified health care professional) should not be making the medical decision of whether a study/procedure is done or not.

Best practice is to have a request/order for each service provided. This helps to remove ambiguity of whether a study can be performed. This is important to know because of the information/criteria present in IOM 100-2 published by CMS regarding Ordering Physician Rules.

I would specifically point you to Section 80.6.1 – 80.6.5 (https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c15.pdf) for detailed and core information on this topic. It is beyond the scope of this forum to go into the intricacies of each section of the document referenced above and again, we strongly recommend that you closely review the material housed in that document.

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