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Bladder Ultrasound


Question

Physician ordered a bladder ultrasound in the ER to check Foley cath placement.  We billed with CPT 76856.  Would there be a more appropriate CPT, i.e. 76857 or 76775?

Answer

According to the CPT manual, code 76856 includes the complete evaluation of the female pelvic anatomy. Elements of this examination include a description and measurements of the uterus and adnexal structures, measurement of the endometrium, measurement of the bladder (when applicable), and a description of any pelvic pathology (eg, ovarian cysts, uterine leiomyomata, free pelvic fluid). Code 76856 is also applicable to a complete evaluation of the male pelvis. Elements of the examination include evaluation and measurement (when applicable) of the urinary bladder, evaluation of the prostate and seminal vesicles to the extent that they are visualized transabdominally, and any pelvic pathology (eg, bladder tumor, enlarged prostate, free pelvic fluid, pelvic abscess).

Code 76857 represents a focused examination limited to the assessment of one or more elements listed in code 76856 and/or the reevaluation of one or more pelvic abnormalities previously demonstrated on ultrasound. Code 76857, rather than 76770, should be utilized if the urinary bladder alone (ie, not including the kidneys) is imaged, whereas code 51798 should be utilized if a bladder volume or post-void residual measurement is obtained without imaging the bladder.

Disclaimer: All articles intended for general guidance only and not as a recommendation for a specific situation. Readers should consult an official source (AHA, AMA, etc.) or a qualified attorney for specific legal guidance.
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