Documentation for ultrasound coding 76830
Ultrasounds are a major part of our practice. Regarding billing code 76830: it “includes imaging of the uterus, endometrium, fallopian tubes, ovaries, and pelvic structures such as the bladder, as indicated. This only refers to a transvaginal ultrasound procedure and a diagnosis should be included.” However, how does it need to be documented. Below is an example of how the transvaginal ultrasound comes across into our system. It does not include fallopian tubes or pelvic structures. Would those two things have to be noted that we viewed them? Is formal documentation written on the ultrasound needed? AAPC states it does need medical necessity, findings, etc.
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Documentation for ultrasound coding 76830
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