ED Coding and Reimbursement Alert

Question: One of our ED doctors is asking to report limited ultrasound of the head. This is the first time I heard of this. What code would I use?

Ohio Subscriber

Answer: CPT® has a section on diagnostic ultrasound of the head and neck. The correct code choice will depend on what the physician was looking for. The two most likely codes for ED presentations are 76506 (Echoencephalography, real time with image documentation [gray scale] [for determination of ventricular size, delineation of cerebral contents, and detection of fluid masses or other intracranial abnormalities], including A-mode encephalography as secondary component where indicated).

If it's ultrasound of the head soft tissue, use 76536 (Ultrasound, soft tissues of head and neck (e.g., thyroid, parathyroid, parotid), real time with image documentation).

Since these are complete rather than limited codes, the interpretive report should address all the elements included in the code descriptor or reasons why they could not be visualized. Otherwise you might consider appending the - 52, reduced services modifier.