ED Coding and Reimbursement Alert

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

Increasingly 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 probing 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 for most of the codes, 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.  Keep in mind some of the ultrasound codes are in the 90000 Medicine section of CPT®. 

Check These 4 Overarching 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 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 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 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 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 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 a region evaluated is visualized or documented, the "limited" code for that anatomic region should be used instead, says Granovsky. 

Ultrasound diagnostic examinations require archived images with the exception of those requiring specific measurements, such as 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging), Granovsky says.  In order for an ultrasound study to be separately coded, there must be a thorough evaluation of organs or anatomic regions, image documentation, and a final, written report. 

For services performed in a facility, the physician, if submitting his own bill, would typically report the interpretation with modifier 26. If billing independently, 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 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 have decided not to 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; and
• 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, some hospitals and payers have imposed credentialing requirements.  If your hospital, state, or a certain payer requires some certification process before deeming a provider eligible to report ultrasound services, it will negatively impact your ability to receive appropriate payment.

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 exam.

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, from 76705 (Ultrasound, abdominal, real time with image documentation; limited [e.g., single organ, quadrant, follow-up]) and 93308 (Echocardiography, transthoracic, real-time with image documentation [2D], includes M-mode recording, when performed, follow-up or limited study)

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 the old records
1 point order of a radiology study

You have now supported 1 area of moderate complexity medical decision making, the amount and complexity of data reviewed.

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

BP 80's, Heart rate 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 [e.g., single organ, quadrant, follow-up]) 
• 93308 (Echocardiography, transthoracic, real-time with image documentation [2D], includes M-mode recording, when performed, follow-up or limited study) 

Keep in mind many groups are also performing an "E" FAST or extended FAST exam which includes a more intensive look at the chest anatomy such as for pneumothorax or hemothorax. Be on the lookout for these elements and if appropriately documented considering adding the code 76604.