Radiology: Diagnostic Ultrasound (September 2007)

September 2007 page 10d Coding Communication:Radiology: Diagnostic Ultrasound Question The guidelines for nonobstetrical ultrasound state that the use of ultrasound without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report is not separately reportable. When reporting code 76857, Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles), does image documentation mean that a photograph of the adnexa was taken and stored for every follicle or for every ultrasound? What does image documentation consist of? AMA Comment Image documentation means that permanently archived images of the exam need to be obtained...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This article explains a radiology coding communication from CPT Assistant focused on diagnostic ultrasound documentation and reporting expectations. It is relevant to coders, radiology practices, and compliance staff who need a general understanding of ultrasound documentation standards, image archiving, and report support for audit purposes. The piece centers on nonobstetrical ultrasound guidance and the documentation elements discussed in relation to CPT Assistant commentary.

Why This Topic Matters

Proper ultrasound documentation affects whether a study is reportable and whether the record supports what was performed. The article helps readers understand the general documentation topics discussed in CPT Assistant for radiology ultrasound services.

Article Sections

  1. Coding Communication: Radiology: Diagnostic Ultrasound

    A coding communication from CPT Assistant discussing diagnostic ultrasound documentation and reporting expectations in radiology.

  2. Question

    A question about documentation expectations for a nonobstetrical pelvic ultrasound service and what image documentation should consist of.

  3. AMA Comment

    An AMA response describing the general concept of image archiving, documentation support, and how records should reflect the performed ultrasound exam.

What You Will Learn

  • The general documentation topics tied to diagnostic ultrasound reporting
  • How the article frames image archiving and written reporting expectations
  • Why ultrasound documentation matters for audit and referral support
  • The broad nonobstetrical ultrasound context discussed in CPT Assistant

Who Should Read This

  • Medical coders
  • Radiology billing staff
  • Compliance professionals
  • Radiology practices
  • Auditors

Codes Discussed


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