ED Coding and Reimbursement Alert

Recent opinion lines up anatomical regions with US codes.

Being that current payer policy on imaging guidance is especially strict, you don't want to miscode any ultrasound (US) services your ED physician provides. CPT Assistant has recently published a Q&A set that will help you get all the reimbursement you deserve for US service, without getting payback requests on improperly coded US.

CPT Assistant poses the question, "When reporting a chest US, is it necessary to include an examination of the mediastinum?"

No; however, if an examination of the mediastinum is indicated, it is included in chest US (76604, Ultrasound, chest [includes mediastinum], real time with image documentation), confirms Elijah Berg, MD, FACEP, CEO of MRSI, an ED coding and billing company in Woburn, Mass.

Impact: While the code descriptor does explicitly mention a mediastinum exam, you can report 76604 regardless of whether or not the physician documents examination of the area. (You cannot, however, report a mediastinum exam separately if the physician notes it during a chest US.)

Where is it? According to Dorland's Dictionary, the mediastinum is: "The mass of tissues and organs between the sternum anteriorly and the vertebral column posteriorly and from the thoracic inlet superiorly to the diaphragm inferiorly. It contains the heart and pericardium, the bases of the great vessels, the trachea and bronchi, esophagus, thymus, lymph nodes, thoracic duct, phrenic and vagus nerves, and other structures and tissues."

CPT Assistant also poses the question, "Which code represents a US of a palpable soft-tissue mass?" You should code this based on the location of the abnormality, CPT says:

• neck: 76536 (Ultrasound, soft tissues of head and neck [e.g., thyroid, parathyroid, parotid], real time with image documentation)

• chest wall, upper back: 76604

• lower back, abdominal wall: 76705 (Ultrasound, abdominal, real time with image documentation; limited [e.g., single organ, quadrant, follow-up])

• pelvic wall, buttock, perineum: 76857 (Ultrasound, pelvic [nonobstetric], real time with image documentation; limited or follow-up [e.g., for follicles])

• upper extremity, axilla, groin, lower extremity: 76880 (Ultrasound, extremity, nonvascular, real time with image documentation)

• other soft tissue: 76999 (Unlisted ultrasound procedure [e.g. diagnostic, interventional]). Previously, there was no uniform guidance on how to code soft-tissue US of the above areas other than the head and neck. Coders were forced to pick the code that most closely described the area the physician was examining, which led to confusion. Now, CPT has made those anatomical US assignments for you, which should make getting paid for these services easier.

Any time you use one of the above US codes for your ED physician's services, be sure to append modifier 26 (Professional component) to show that you are only coding for your physician's work, not the US equipment.

Example: The ED physician performs US on a patient's groin to examine an unidentifiable mass. On the claim, you'd report 76880-26.