Health Information Management

Q/A: Correct coding for unilateral venous Doppler on upper and lower extremity

APCs Insider, August 6, 2010

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Q: We performed a unilateral venous Doppler on a patient in our imaging center for the right upper extremity. During the same session, we also performed a unilateral venous Doppler for the right lower extremity. I know I can append modifier -RT, but because the way in which a venous Doppler is performed I need to use code 93971 (duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study) twice for the upper and lower extremity. 

If I report 93971 twice with the -RT modifier, may I add modifier -59 to one of the studies? It is my understanding that I can’t use the bilateral code (93970) because different extremities (arms and legs) are involved.

A: You are correct, you may not use a bilateral code because bilateral means two sides, and that is inapplicable in this scenario.

I suggest reporting 93971-RT + 93971-59-RT. Include a report to explain that one was an upper extremity and the second was a lower extremity.

Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI.



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