Coding and documentation for Vascular Doppler Ultrasound procedures has always been challenging because the specific CPT language does not encompass the various technologies utilized. In 2008, CPT added the requirement that both color and spectral Doppler need to be reported in order to bill the Duplex code(s). Since that time, ADVOCATE has provided recommendations for documenting vascular Doppler ultrasound procedures that would include this information.
Recent literature on this topic reaffirms the documentation requirement for Duplex scans, and goes on to give a directive that if the appropriate documentation is not in the report, a non-vascular ultrasound code should be assigned. The AMA, ACR, and other resources in the industry have provided guidance on the documentation and appropriate coding for these procedures when the recommended language is and is not included in the report.
All sources have affirmed that documentation of the assessment of flow with color, recording a spectral waveform, and a report of the findings should all be present in the report in order to assign a Duplex CPT code. If this documentation is not in the report, a non-vascular ultrasound code should be assigned, representing a decrease in reimbursement. See code descriptions and reimbursements below.
The following documentation would support assigning a Duplex CPT code:
“Duplex scan of the body site performed using B-Mode/gray scale imaging and Doppler spectral analysis and color flow”.
Without the proper documentation:
- 93975/93976 $89/$60: Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; (Complete/Limited) would be down coded to – 76705 $29: Limited abdominal US
- 93970/93971 $35/$22 : Duplex scan of extremity veins including responses to compression and other maneuvers; (Bilateral/Unilateral) would be down coded to 76882 $24 : Limited extremity US
- 93925/93926 $40/$25 : Duplex scan of lower extremity arteries or arterial bypass grafts; (Bilateral/Unilateral) would be down coded to 76882 $24: Limited extremity US
- 93880/93882 $29/$21: Duplex scan of extracranial arteries; (Bilateral/Unilateral) would be down coded to – 76536 $28 Head/neck soft tissue US
Jennifer Bash, RHIA, CPC, CIRCC, RCC
Coding & Documentation Education Manager