Ask Dr. Z

A patient had a penile duplex examination performed after injected with alprostadil (prostin VR). Does this documentation support CPT 93980 and also CPT 54235? Does the actual injection administration need to documented?

“A penile duplex examination was performed pre and post injection. In the resting state, the cavernosal arteries were high resistant with low velocity flow. The immediate post injection images demonstrated medication microbubbles appropriately within the cavernosal compartments. The post injection cavernosal arterial hemodynamics during tumescence were low resistance with increased velocity (>25-30 cm/sec). The cavernosal Doppler waveform resistive index increased to >0.90 and was maintained for 10 minutes. Systolic rise times were within normal limits (<100 ms). The dorsal artery was patent with a normal Doppler profile. The dorsal vein flow during maximal response was absent. There were no dorsal to cavernosal perforators identified. Conclusions: Patent bilateral cavernosal arteries with normal response to injection.”