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A complete abdominal ultrasound is ordered, however, all abdominal structures are not documented as identified, what service(s) should be assigned?

a. Abdominal ultrasound complete
b. limited or follow-up ultrasound with modifier -52
c. limited or follow-up ultrasound only
d. abdominal ultrasound, complete with modifier -52

1 Answer

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Final answer:

For an incomplete abdominal ultrasound, a limited or follow-up ultrasound with modifier -52 should be used to reflect the service provided. Modifier -52 indicates a reduced or limited service due to not all structures being visualized and documented.

Step-by-step explanation:

If a complete abdominal ultrasound is ordered, but not all abdominal structures are documented as identified, the correct service to assign is a limited or follow-up ultrasound with modifier -52. Modifier -52 is used to indicate a reduced service, signifying that the ultrasound was partially reduced or limited because not all structures were visualized and documented. Therefore, the proper billing code would reflect that a limited service was provided rather than a complete one.

It's important to note that an abdominal ultrasound is typically used to detect various conditions, such as gall stones or a pancreatic pseudocyst. However, the quality of the ultrasound images can be operator-dependent and may be affected by various factors, including a patient's body composition. For example, it is more challenging to obtain a high-resolution ultrasound image in the abdominal region of someone who is overweight compared to someone with a slight build due to the increased density of tissue and fat that can absorb or scatter the sound waves, making it harder to obtain a clear image.

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