Complete Abdominal Ultrasound
These topics describe the Complete Abdominal Ultrasound alert.
Purpose
To ensure that contrast is not documented on an imaging exam specified as non-contrast or without contrast only. Reports that have IV contrast documented will appear on a list in the Scout > Doc Quality > Contrast documented on a non-contrast exam folder.
Details
A complete abdominal ultrasound requires documentation of the following organs in order to be billed as a complete exam (CPT 76700). If a Complete Abdominal study is ordered but the required documentation is not present to support it, it 1) cannot be coded as complete and may be down-coded to a limited exam (CPT 76705), resulting in reduced reimbursement; and 2) may be sent back to the radiologist to correct, resulting in added time to create an addendum, thus delaying billing.
Documentation of the following organs is required:
Liver
Pancreas
Spleen
Gallbladder
Common bile duct (CBD)
Kidneys
Upper abdominal aorta
Inferior vena cava (IVC)
Modalities, exams, body structures, and sections
The NLP reasons over specific modalities, exams, and/or report sections for each alert. A summary of the inclusions for the "Complete abdominal ultrasound" exam are provided below.
Included | |
|---|---|
Modalities | Ultrasound |
Exams | Complete abdominal ultrasound (CPT 76700) |
Report sections | All |
Functionality
If one or more required organs are missing from the documentation, a general alert will fire that informs the provider that the documentation is incomplete with a specific alert identifying each organ that is missing.
Examples for testing
The following examples are provided to help you understand which reports will appear in Scout. The dictation phrases are for demonstration purposes only and may not be clinically accurate.
Exam type | Dictation phrase | Expected Assist alert(s) |
|---|---|---|
Complete abdominal ultrasound | FINDINGS: LIVER: Normal echogenicity. BILIARY: No gallstones. No intra- or extra- hepatic bile duct dilatation. Common bile duct measures 0.5 cm. AORTA: Within normal limits. IVC: Within normal limits. RIGHT KIDNEY: Long axis 11.2 cm, unremarkable. LEFT KIDNEY: Long axis 10.8 cm, unremarkable. SPLEEN: 14 cm, unremarkable. | Gall Bladder and pancreas were omitted from the report; therefore the following 2 alerts would fire: "Explicit mention of pancreas required for complete abdominal US exam" "Explicit mention of gall bladder required for complete abdominal US exam" |
Complete abdominal ultrasound | FINDINGS: LIVER: 16 cm in long axis with increased echogenicity. COMMON BILE DUCT: 0.5 cm. No intra or extra hepatic bile duct dilation. GALLBLADDER: No gallbladder wall thickening. Negative sonographic Murphy's sign. RIGHT KIDNEY: 10.7 cm. No hydronephrosis or renal calculi. LEFT KIDNEY: 10.6 cm. No hydronephrosis or renal calculi. PANCREAS: Visualized portion within normal limits. AORTA: Visualized portion unremarkable. OTHER: No ascites. | Spleen and IVC were omitted from the report; therefore the following 2 alerts would fire: "Explicit mention of spleen required for complete abdominal US exam" "Explicit mention of inferior vena cava (IVC) required for complete abdominal US exam" |
Complete abdominal ultrasound | FINDINGS: LIVER: 16 cm in long axis with increased echogenicity. COMMON BILE DUCT: 0.5 cm. No intra or extra hepatic bile duct dilation. GALLBLADDER: No gallbladder wall thickening. Negative sonographic Murphy's sign. RIGHT KIDNEY: 10.7 cm. No hydronephrosis or renal calculi. LEFT KIDNEY: 10.6 cm. No hydronephrosis or renal calculi. PANCREAS: Visualized portion within normal limits. SPLEEN: Unremarkable VASCULAR: Visualized aorta and inferior vena cava unremarkable. OTHER: No ascites. | No alert will fire because all organs are identified within the report satisfying the requirement for a complete abdominal ultrasound. |