ED Coding and Reimbursement Alert

Social and economic pressures to triage, diagnose and rapidly treat patients have fueled ultrasounds use as a primary examining tool in the ED. Applicable codes typically include abdomen and retroperitoneum (76700, 76705, 76770, 76775 and 76778), pelvis (76805, 76810 and 76815-76816) and extremities (76880 and 76885-76886).

Bedside ultrasounds allow ED physicians to diagnose selected conditions accurately, report faster turnaround times and offer more expedient diagnoses of potential life-threatening emergencies, such as internal hemorrhage following a blunt trauma, abdominal emergencies, pericardial tamponade and aortic aneurysms. Ultrasounds mean quicker and more accurate diagnosis, which ultimately means fewer blood transfusions, confirms Stephen Hoffenberg, MD, FCEP, president of CarePoint PC, an emergency physician group practice in Denver. According to a recent study, emergency physician-performed pelvic ultrasound decreased the length of stay in the ED by a median of 120 minutes.

Hoffenberg suggests many ED physicians and coding companies dont charge for bedside ultrasounds because they simply dont know how or because the procedure may be repeated in the radiology department, leading to fears of double-dipping. But knowing how to code for limited study and appending the proper modifiers typically eliminates billing errors.

David McKenzie, director of reimbursement at the American College of Emergency Physicians (ACEP), explains that ED ultrasounds are typically limited, goal-directed examinations used to answer specific clinical questions. Although ultrasounds in the ED have become a delicate issue with radiologists, the exams are generally not comprehensive and rarely replace the formal sonography offered by the department of radiology. The ED might perform a comprehensive exam, however, for patients sent immediately to the operating room with pericardial effusion, intraperitoneal fluid or an abdominal aortic aneurysm, for example.

Choosing the Correct Modifier

Several modifiers, including -26 (professional component), -52 (reduced services), -76 (repeat procedure by same physician) and -77 (repeat procedure by another physician), may apply when coding ultrasounds in the ED.

Because the ED physician does not own the equipment, he or she may not collect for the technical component of the procedure and must always append modifier -26 to the appropriate CPT code.

Modifier -52 indicates that under certain circumstances a service or procedure is partially reduced or eliminated at the physicians direction. For example, the ED physician may perform a transvaginal probe. A radiologist performing such an ultrasound would look at the entire view and appropriately apply the transvaginal probe code 76830. The ED physician suspecting an abnormal pregnancy, however, would more than likely take a more limited view, looking only at the uterus and pelvic pericardium. In such a case, 76830 should be reported with modifier -52 appended to designate the reduced service.

Modifiers -76 and -77 indicate that either the original physician or another physician (typically a radiologist) must repeat the service. For example, a patient presents with abdominal pain. The ED physician performs an ultrasound, which reveals blood in the belly. The patients blood pressure drops, prompting the original physician to perform a second ultrasound. Modifier -76 should be appended to 76705 to indicate the repeat procedure.

Modifier -77 would be appended, for example, if the ED physician performs the ultrasound but then transfers the patient to the trauma ward, where the trauma surgeon performs the second ultrasound.

Document Scope of Procedure

Medicare requires a hard-copy document of every ultrasound study. This does not have to be a separate report,(the procedure note is most often included in the body of the medical record), but it does have to be a signed, identified procedure note, Hoffenberg explains. Physicians must identify the scope of the procedure, what the procedure was and who did it. In addition, they should document what was found on the ultrasound and indicate the medical necessity for the test.

Documentation is everything if you dont document properly you dont meet the criteria to charge for it, Hoffenberg cautions. The goal is not to run up charges but to reflect accurately the procedure performed.

Coding for FAST Exams

The focused abdominal sonography for trauma (FAST) exam is a new ultrasound procedure rapidly replacing the costly CT scan and the more invasive diagnostic peritoneal lavage (DPL). The procedures only objective is the detection of free intraperitoneal fluid in blunt abdominal trauma.

The ACEP Coding and Nomenclature Advisory Committee and the ACEP Ultrasound Section have been looking at how to code the FAST exam in the ED properly. The group recommends using existing CPT codes 76705 (echography, abdominal, B-scan and/or real time with image documentation; limited [e.g., single organ, quadrant, follow-up]) and 93308 (echocardiography, transthoracic follow-up or limited study). A new CPT code for the procedure will not be available until 2003 at the earliest.