Documentation Tip: Duplex Studies
In order to bill for a diagnostic vascular imaging study with Doppler (Duplex), documentation must support the following parameters:
- B-mode/2D gray scale imaging of vascular structures
- Doppler spectral analysis (waveforms)
- Color flow
It is not appropriate to report a duplex scan code unless evaluation of vascular structures are performed using both spectral and color Doppler.
Abdominal/Pelvic Duplex Studies
Duplex scanning of arterial inflow/venous outflow of abdominal, pelvic, or retroperitoneal organs may be coded with CPT code 93975, or with CPT code 93976, depending on whether a complete or limited study is performed.
- Complete (93975): This code is used for duplex evaluation of arterial supply and venous drainage of an organ or organs in the abdomen, retroperitoneum, or pelvis. The code is the same whether one or more organs are evaluated. For organs that are bilateral (eg, ovaries), both should be completely assessed for use of this code.
- Limited (93976): This code is used when only part of an organ is evaluated or the study is otherwise limited (eg, arterial only or venous only evaluation of both ovaries or arterial and venous evaluation of one ovary but not the other). It is also used for follow-up duplex investigation of an organ or organs (eg, evaluation of vascular supply of a transplanted liver).
The Duplex study may be coded in addition to an abdominal, pelvic, or retroperitoneal real time ultrasound study, when the following parameters are met:
- both are ordered by the referring physician due to medical necessity
- both studies are performed and documented
Advocate recommends dictating a separate paragraph describing the vascular portion of the study. Not only should the technique describe that the spectral analysis and color flow were performed, but there should also be clear findings describing the spectral analysis and color flow in the report.
It is important to remember that the duplex study represented by codes 93975/93976 should not be coded when a quick look with color Doppler is done to check whether flow is present or for structure identification.
