Ask Dr. Z

Related to pelvic, abdominal, and retroperitoneal ultrasounds, we understand that code 93975 or 93976 should not be reported in addition to the base ultrasound code when used for a quick assessment of blood flow or to simply identify a structure. Could you help us clarify for our physicians what elements should be seen in the report in order to substantiate these codes? This is an example of what we often see: "Technique: Transabdominal and transvaginal imaging, 2D gray scale, color Doppler, spectral waveform analysis. Findings: Uterus measures XX, uterine fundus circumscribed hypoechoic structure measuring XX. Another located in the posterior fundus measures XX. Endometrial measures XX. No endometrial fluid seen. Overlying bowel gas structures obscures right ovary. Left ovary measures XX. It demonstrates normal color flow Doppler and spectral waveform analysis. No free fluid seen." Could you please review and clarify if there is sufficient documentation to report codes 93975/93976 in addition to pelvic and transvaginal ultrasound codes?