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What makes an extremity ultrasound complete?

NON-VASCULAR EXTREMITY ULTRASOUNDS – WHAT MAKES AN EXTREMITY COMPLETE?

Complete vs. limited exams are a consistent source of questions and noncompliance. For ultrasound exams, some of our most frequent questions are around understanding the guidelines for complete vs. limited exams. Many of the code choices for ultrasounds make the distinction between a complete exam and a limited exam. The elements required for an exam to be complete are listed either in the code description itself (the long description), or in the guidelines within the CPT® manual. The requirements to code for a complete ultrasound are just that: complete. Meaning if less than the required elements for a complete exam are reported in the documentation, the complete code is not appropriate, and the limited exam code should be used.

In particular, one exam we receive a lot of questions on is non-vascular extremity ultrasounds and what’s required to report a complete exam.

Extremities – What’s Complete?

As complete ultrasound codes go, 76881 for non-vascular extremity ultrasound is very complete, requires a lot of imaging and detailed documentation for all of it. The code description is as follows:

76881  Ultrasound, complete joint (ie, joint space and peri-articular soft tissue structures) real-time with image documentation

Now, that doesn’t seem too intense, but this code is describing a complete evaluation of a specific extremity (upper or lower) joint and requires examination of the following:

  • The joint space (e.g., effusion)
  • Peri-articular soft tissue structures around the joint such as muscles, tendons or other soft tissue structures)
  • Other identifiable abnormalities
  • Additional evaluations such as dynamic imaging or stress maneuvers as necessary

As with all ultrasounds, permanently recorded images are required along with a written report describing all the above requirements, or reasons why any could not be captured.

Extremities – What’s Limited?

76882  Ultrasound, limited, joint or other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft tissue structure[s], or soft tissue mass[es]), real-time with image documentation

Most of the time with non-vascular extremity ultrasounds, the exam is not going to be complete and the limited code (76882) will be used. Code 76882 describes the limited evaluation of a joint (meaning less than the required elements for a complete exam are imaged) or imaging of structure(s) within an extremity (non-vascular) other than a joint such as fluid collection, soft tissue masses, nerves, muscles, tendons, etc.

Some frequent questions relating to limited extremity ultrasounds include:

“How should the evaluation of a soft tissue mass on an extremity be reported?” and “What would be the correct code for an ultrasound of the axilla when performed alone?”

The answer to both questions is 76882.

What if Multiple Joints are Examined?

One of the most common questions relating to these codes is: How many times can 76881 or 76882 be billed when multiple joints are evaluated during the same patient encounter?

The answer here continues to be a little gray, as currently no specific document or piece of guidance exists stating whether these codes may be submitted more than once for the same patient encounter when ipsilaterally multiple joints have been imaged for a clinical diagnosis other than a joint survey for arthritis (if multiple joints are evaluated by ultrasound for an arthritis survey, reported unlisted code 76999 instead of 76881 or 76882). Additionally, the code definitions do not indicate that more than one joint is imaged within the definition since there is no use of ‘s’ applied to the word ‘joint’. Therefore, when medically necessary and when there are specific orders requesting the imaging of more than one joint in the same extremity, code 76881 or 76882 may be reported for each joint examined. Be aware that current CCI edits show an MUE value of 2 and MAI of 3 for each of these codes.

Complete Guidance for Complete and Limited Exams

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