ED Coding and Reimbursement Alert

Diagnostic imaging services are under increased payer scrutiny. Learn these tips to make sure your code choices are secure.

More and more EDs are using ultrasound services for diagnosis, but ED coders may not be fully up to speed on reporting these quick and non-invasive visualizations. Take a close look at the advice that follows to get an easy-to-apply view of the requirements for successful ultrasound billing.

Getting started: For diagnostic ultrasound codes, look in the radiology section of the CPT® book using codes 76506 through 76999, instructs Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a medical coding and billing company in Bedford MA . The codes are organized by anatomic area with greater specificity of organs or structures visualized grouped by specific study. (See Sidebar for common ED ultrasound procedures)

Check These 4 Overarching CPT® Requirements

The preamble to the diagnostic ultrasound section of CPT® lists these 4 requirements:

1. Medical necessity -- The medical record documentation must indicate why the test was medically necessary. Payers have expressed concerns that imaging in general and ultrasound in particular are being over utilized 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 be 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. Identify the provider -- 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 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 in the introductory section language or specific code descriptor, says Granovsky.

As an example, the CPT® language in the introduction to the abdominal and retroperitoneum ultrasound section reads as follows "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 region evaluated is visualized or documented, the "limited" code for that anatomic region should be used instead., says Granovsky

He goes on to say, all ultrasound diagnostic examinations require recorded images with measurements when such measurements are clinically indicated. In order for an ultrasound study to be separately coded, there must be a thorough evaluation of organ(s) or anatomic regions, image documentation, and a final, written report. Without all of these elements the examination is not separately reported and would be considered part of any Evaluation and Management service which occurred during that session.

For services performed in a facility, the physician would typically report the interpretation with modifier 26. Even if the physician personally performs the ultrasound rather than a tech, use of the code without a modifier may not be appropriate as the facility has provided the room and most likely the equipment, Granovsky adds.

Be Aware of These Barriers to Successful Ultrasound Reporting

Your emergency physician group may perform ultrasound testing but may not separately bill for those procedures due to several recurring factors. A recent survey by the American College of Emergency Physicians (ACEP) Ultrasound Section lists these potential barriers to successfully ultrasound reporting:

• Archiving the required images
• Documenting a full report
• Political issues within the hospital
• Low reimbursement for the codes
• Payers not recognizing emergency physician training to provide ultrasound services
• Payers rejecting ultrasound services as being separately payable with an E/M code

The survey results didn't identify any of these as "major barriers" to billing for the codes, but be aware that they can present some challenges.

Although CPT® does not specifically require an emergency physician to be credentialed to provide ultrasound services, a hospital or payer may. If your hospital, state, or a certain payer requires some certification process before deeming a provider eligible to report ultrasound, it will negatively impact your ability to get paid.

Capture MDM Points for E/M 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 and the direct visualization of the study can add points in the amount and complexity of data reviewed section, which are counted towards the overall MDM score.

Consider these coding examples from Granovsky:

Example 1 A 35-year-old male drives into a tree at 30 miles per hour. His vital signs are stable but he then becomes tachycardic and complains of abdominal pain. He experiences no loss of consciousness but complains of neck pain.

The work up included a physical exam, a C-spine x-ray series, lab work, and a FAST exam with documentation of direct visualization of the images for the abdominal and cardiac components of the FAST (see EDCA archive story on FAST exams Vol. 14, No 6, p. 37).

According to a typical Marshfield Clinic Score Sheet grid, you have supported one of the requirements for high complexity MDM by scoring a total of four data points:

• 1 point for ordering the C spine X ray
• 1 point for review of the lab work,
• And with addition of the ultrasound study,
• 2 points for the independent visualization of the ultrasound images.

Example 2 A 55-year-old male presents with a painfully red swollen area on the right lower leg. He has a history of insulin dependent diabetes and a pulse of 102 with a low grade fever.

The clinical course includes a CBC, an order for the old records, as well as ordering an ultrasound exam of the lower extremity to evaluate for the presence of an abscess.

According to a typical Marshfield Clinic-type scoring grid, you might score the following with regard to amount and complexity of data reviewed:

• 1 point for ordering for a clinical lab test (CBC)
• 1 point for decision to obtain old records (the ultrasound)
• 1 point order of a radiology study

You have now supported 1 area of moderate complexity medical decision making.

Example 3 A 25-year-old male presents to the ED following a rollover MVA. Vitals are as follows:

BP 80's, HR 120, Belly firm. The physician is concerned about a ruptured spleen and performs a FAST exam evaluating both the abdomen and the pericardial area. Documentation of both the abdominal and cardiac components are present in the record.

The following ultrasound codes would be reported:

• 76705 (Ultrasound, abdominal, real time with image documentation; limited)
• 93308 (Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study).