ED Coding and Reimbursement Alert

Question: What documentation is required to bill ultrasounds that the ED physician performs?


Delaware Subscriber

Answer: According to information issued by the American College of Emergency Physicians (ACEP), you-ll need four things: a separately identifiable written interpretation and report of the ultrasound, documentation of medical necessity for the test, a description of the organs or structures the physician studied, and a permanently recorded image.

The written interpretation and report can take the form of a separate procedure note within the ED medical record, such as those that accompany lumbar puncture or central line placement, or a separate note that the physician attaches to the medical record.

Tips:

- Identify who performed the procedure in the report. According to the ACEP sheet, -This will help avoid confusion as to whether the physician performed and interpreted the test or simply reviewed the report of another provider.-

- Make sure the physician documents the full scope of the study--whether it was complete or limited, a repeat examination by the same physician, a repeat examination by another physician, or a reduced level of service.

Example: ACEP offers the following example of a well-documented ultrasound report:

-I performed a limited transvaginal ultrasound exam of the pelvis to evaluate for IUP vs. signs of ectopic pregnancy in a patient with a positive pregnancy test and vaginal bleeding. The uterus and pouch of Douglas were visualized. There was a small (physiological) amount of free fluid in the pelvis. The uterus had an endometrial stripe of 12 mm with no definite sign of IUP. Impression: No evidence of an intrauterine pregnancy.-