Case
-AUDIT REPORT T2.2 ULTRASOUND, LOWER EXTREMITIES
LOCATION: Outpatient, Hospital
PATIENT: Daniel Adams
REQUESTING PHYSICIAN: Alma Naraquist, MD
PHYSICIAN: Morton Monson, MD
EXAMINATION OF: Ultrasound of both lower extremities
CLINICAL SYMPTOMS: Leg pain
ULTRASOUND OF BOTH LOWER EXTREMITIES: FINDINGS: Ultrasound examination of the deep venous system of the lower extremities shows a deep venous thrombosis of the superficial femoral vein of the right leg. Bilateral posterior tibial, greater saphenous, femoral and popliteal veins are patent with no evidence of thrombus seen there.
T2.2:
SERVICE CODE(S): 93971-50__________________________________________
ICD-10-CM DX CODE(S): M79.661, M79.662, I82.411______________________
INCORRECT/MISSING CODE(S): _____________________________________

Question

Quizplus · Accepted Answer

The Answer is INCORRECT/MISSING CODE(S): 93971-50, M79.661, M79.662, Modifier -26
Explanation: This is a bilateral test of the veins of the legs and is reported with 93970 to indicate a bilateral duplex scan of the extremities. Modifier -26 is added to indicate the physician portion of the service. The hospital reports the facility portion of the service.
The diagnosis is femoral thrombosis of the right leg reported with I82.411. The clinical symptoms indicate leg pain for which the ultrasound was ordered; however, the study indicated a more definitive diagnosis of thrombosis of the right femoral vein, so the leg pain is not reported.

Case -AUDIT REPORT T2.2 ULTRASOUND, LOWER EXTREMITIES