ED Coding and Reimbursement Alert

It's a common emergency department scenario: The physician orders an ultrasound for a female patient with abdominal pain or vaginal bleeding. You apply routine obstetric or pelvic ultrasound codes, but they don't deliver payment.

Pregnancy ultrasound coding can bring on labor pains you didn't expect. Learn its subtle nuances to ease the struggle and ensure accurate codes. When treating females with pain and bleeding, emergency physicians must distinguish between intrauterine death (e.g., 656.4 series), spontaneous abortion (634 series), ectopic pregnancy (633 series) disorders of the ovary, fallopian tube, and broad ligament such as ruptured ovarian cyst or ovarian torsion (620 series), and other conditions.

Bedside ultrasound helps ED physicians quickly identify the presence of an intrauterine pregnancy, for example. An ultrasound also detects the presence of free fluid in the pelvic peritoneum a condition that determines critical clinical decision-making.

Choosing the appropriate code to ensure reimbursement for this type of US depends on criteria that are tough to discern, warns Stephen Hoffenberg, MD, chairman-elect of the ultrasound sections of the American College of Emergency Physicians (ACEP) and president of CarePoint, a 150-physician emergency group in Denver.

Two criteria determine codes for ultrasounds evaluating abdominal pain and vaginal bleeding. You must determine both the patient's pregnancy status and the symptoms that necessitated the service, Hoffenberg says.

If the physician knows about the pregnancy before he performs the ultrasound, and the US evaluates pregnancy-related conditions, then use an obstetric pelvic code for ultrasound, e.g., 76815 (Ultrasound, pregnant uterus, B-scan and/or real time with image documentation; limited [fetal size, heart beat, placental location, fetal position, or emergency in the delivery room]), Hoffenberg says.

Apply these obstetric ultrasound codes to pregnant patients who require ultrasounds for pregnancy-related conditions regardless of test results. The ultrasound could reveal an ectopic pregnancy, a spontaneous abortion or a molar pregnancy, but it could expose a nonpregnancy-related condition instead. Apply the obstetric codes from the 768xx series regardless, Hoffenberg says. These codes accurately capture services rendered to the "known to be pregnant" patient.

Most of the time, emergency physicians know that the patient is pregnant, and the ultrasound evaluates a pregnancy-related condition, says Vivek Tayal, MD, an emergency physician at Carolina Medical Center in Charlotte, N.C., and contributor to the ACEP ultrasound reimbursement paper. "The most common code and more accurate code for most emergency physicians is the limited pelvic ultrasound where pregnancy is known, 76815," he states.

But it's important to have solutions to other coding scenarios in your repertoire, Tayal adds.

For example, an ultrasound was ordered to evaluate gallstones, a nonobstetric condition, in a pregnant patient. Because the exam evaluated a condition unrelated to pregnancy, you should not code the ultrasound with an obstetric code despite her pregnancy, Hoffenberg says. Use an abdominal code instead to capture an evaluation for gallstones in a patient, e.g., 76705 (Ultrasound, abdominal, B-scan and/or real time with image documentation; limited [e.g., single organ, quadrant, follow-up]).

Likewise, apply the nonobstetric pelvic code 76857 to the evaluation of urinary retention in a pregnant patient.

You may be tempted to apply obstetric codes to all pregnant patients receiving ultrasounds, but that assumption will lead to denials, Hoffenberg says. The obstetric codes apply to pregnant patients when the ultrasound evaluates the pregnancy or a related condition. If the US didn't evaluate pregnant conditions, you should apply the appropriate abdominal, pelvic or retroperitoneal codes instead.

When the patient's pregnancy condition is unknown before examination, apply the nonobstetric pelvic codes, e.g., 76857 (Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; limited or follow-up [e.g., for follicles]), Hoffenberg says. Do not use the obstetric pelvic codes for ultrasounds evaluating pelvic pain, amenorrhea, vaginal bleeding or non-gynecologic pelvic pathology in this scenario, he warns.

Obstetric codes don't come into play when pregnancy status is unknown prior to the US, even when ultrasound results reveal a pregnancy, Hoffenberg says.

Emergency physicians may use a transvaginal ultrasound to conduct a more thorough investigation of an area of the body already captured by a prior ultrasound. For example, a physician might order a transvaginal ultrasound to gain a higher-resolution view of the intrauterine structures shown in a transabdominal ultrasound.

If both ultrasounds are medically necessary, then code separately for both, Hoffenberg says. Be sure to consult your clinical requirements for ultrasound procedures to find out if you should only code for the transvaginal exam, he advises, and remember that the transvaginal code does not depend on pregnancy status.

The appropriate transvaginal code 76830 (Ultrasound, transvaginal) typically requires modifier -52 (Reduced services) when you code pregnancy ultrasounds in the ED department, Hoffenberg says.

Emergency physicians usually conduct focused transvaginal exams. There is no corresponding limited procedure to the transvaginal code 76830 a complete examination of all structures within the anatomic description so coders need to tack on modifier -52 when documentation indicates a limited exam, he says.

Occasionally, ED physicians administer full transvaginal ultrasound exams, but Tayal cautions against liberally applying the full examination code. He suggests sticking to a limited pelvic exam code to describe the entire procedure ultrasound and any additional probing.

The 76815 code is "safer," Tayal says. Often professionals conducting the full exam "don't get a picture, don't see the left ovary, or didn't visualize it," he says. And even though just looking at the ultrasound could technically qualify for reimbursement, he says, "it's just safer from a coding regulatory point of view to use 76815."

As additional advice, Hoffenberg emphasizes how important it is to match the appropriate ICD-9 code to the exam. The ICD-9 code must reflect the medical necessity of performing the diagnostic ultrasound. Was it for pelvic pain (e.g., 625.9) or amenorrhea (e.g., 626.0)? An excellent resource for carrier policies regarding coding and medical necessity can be found at www.lmrp.net.

Hoffenberg notes that ultrasounds are typically poorly documented. Obtain proper documentation from physicians, Hoffenberg says. As always, CMS requires documentation similar to that of a specialist in the field and consistent with the service provided. ED Coding Alert will cover ultrasound documentation more fully in a future issue.