ED Coding and Reimbursement Alert

Extent of the exam, medical necessity and an archived image are all required to secure payment

Diagnostic ultrasound studies are more common in the ED setting thanks to the technology's ability to help triage, diagnose and rapidly treat patients. Improvements in point of care technology and extensive training in ultrasound use in emergency medicine residencies both inspire emergency physicians to turn to this technology more and more frequently. Identifying the proper code to capture the ultrasound study performed requires a thorough knowledge of how this code set is structured.

Bedside ultrasound allows emergency physicians to diagnose selected conditions accurately, report faster turnaround times and can foster rapid diagnoses of potential life-threatening emergencies, such as internal hemorrhage following a blunt trauma, abdominal emergencies, pericardial tamponade and aortic aneurysms, says Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, Founder and Chairman of Edelberg + Associates in Atlanta.

Study These Ultrasound Documentation Requirements

Most diagnostic ultrasound codes are found in the radiology section of CPT^®.  The codes are organized by anatomic area with greater specificity of organs or structures grouped by specific study. However, there are additional ultrasound codes found in the 90000 Medicine section of the CPT^® book says Edelberg.

Make Note of These Four Overarching Requirements

1. Medical necessity - The medical record documentation should indicate why the ultrasound study was medically necessary. Payers have expressed concerns that imaging in general and ultrasound in particular are being overutilized based on significant increases in reporting volume. Be sure the diagnosis or symptoms that indicated the need for the ultrasound study are included on your claim.

2. Interpretation - A written interpretation and report must be completed and maintained in the patient's medical record.  The report should note the organs or anatomical areas studied, and include an interpretation of the findings.

3. Provider Identification - The record should be clear about who is performing and/or interpreting the study.

4. Image Retention - An appropriate image(s) of the relevant anatomy and/or pathology must be permanently stored and available for future review. 

Distinguish Between Complete vs. Limited Exams

CPT^® makes a point to distinguish between those codes in certain anatomic regions that describe "complete" and "limited" ultrasound codes. The elements that comprise a "complete" exam are typically listed in the introductory section language or specific code descriptor, says Edelberg.

For example: The CPT^® language in the introduction to the abdominal and retroperitoneum ultrasound section advises "A complete abdominal ultrasound (76700) would consist of real time scans of the: liver, gall bladder, common bile duct, pancreas, spleen, kidneys, upper abdominal aorta and inferior vena cava."

In this case, the report should contain a description of all the listed elements or the reason that an element could not be visualized, such as when the gall bladder has been previously surgically removed and not present for a complete abdominal exam. If less than all the required elements for a "complete" exam are reported, as when a limited number of organs or a limited portion of a region  being evaluated is visualized or documented, the "limited" code for that anatomic region should be used instead, says Edelberg. 

For services performed in a facility, the physician, if submitting his own separate bill, would typically report the interpretation with modifier 26. If billing independently for the physicians, even if the physician personally performs the ultrasound rather than a tech, use of the code without a modifier may not be appropriate if the facility has provided the room, the overhead and most likely the equipment, Edelberg adds.

Imagine You Were Asked To Produce the Image

The first sentence in the CPT^® Diagnostic ultrasounds section reads, "All diagnostics ultrasound examinations require permanently recorded images with measurements, when such measurements are clinically indicated." There is an exception for those codes whose sole diagnostic purpose is a biometric measurement, such as for code 76516 (Ophthalmic biometry by ultrasound echography, A-scan). For the majority of ultrasound studies, failure to have the image archived and retrievable would fail to meet the first requirement for the code, Edelberg warns.

Don't Forget To Add the Correct Modifier for Your Ultrasound Code

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.

If the ED does not own the equipment, the physician may not collect for the technical component of the procedure and must append modifier 26 to the appropriate CPT® code, instructs Edelberg.

Modifier 52 indicates that under certain circumstances a service or procedure is partially reduced or eliminated at the physician's 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 (Ultrasound, transvaginal). The ED physician suspecting an abnormal pregnancy, however, might take a more limited view, looking only at the uterus and pelvic pericardium. In such a case, 76830 could be reported with modifier 52 appended to designate the reduced service.

Modifiers 76 and 77 indicate that either the original physician or another physician 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 patient's blood pressure drops, prompting the original physician to perform a second ultrasound. In this scenario, append modifier 76 to 76705 (Ultrasound, abdominal, real time with image documentation, limited [e.g., single organ, quadrant, follow-up]) to indicate the repeat procedure.

Append modifier 77, 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.

Score E/M Code MDM Points with Ultrasound

Even if you do not bill separately for ultrasounds because of credentialing or turf issues in your facility, the ultrasound may contribute to the overall medical decision making (MDM). Ordering a test scores 1 point and the direct visualization of the study can potentially add 2 points in the amount and complexity of data reviewed sections, which are counted towards the overall MDM score, says Edelberg.