Medicare Compliance & Reimbursement

Question: Is it feasible to use ultrasound rather than fluoroscopy for guidance when inserting a lumbar epidural catheter for post operative pain? If so, can the ultrasound be submitted to the carrier? Which codes would apply?

Answer: Medicare reimburses for ultrasound services when the services are within the scope of the provider’s license and are deemed medically necessary. It is entirely up to the physician to choose which imaging services are required in a particular situation.

Office services: In the office setting, a physician who owns the equipment and performs the ultrasound guidance may report the global/non-facility code and report the CPT® code without any modifier, such as 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation). The current national non-facility fee for 76942 based on the Medicare conversion factor of $35.8228 is $74.15, with a total national non-facility RVU of 2.07.

Outpatient or ASC services: If the site of service is a hospital or an ambulatory surgical center (ASC), append modifier 26 (Professional service) to the CPT® code for the imaging service. That’s because even though 76942 isn’t approved for separate ASC payment to the facility, the physician will still get reimbursed for his work. Based on the Medicare Outpatient Prospective Payment System (OPPS), the technical component of image guidance procedures performed in the hospital outpatient department or ASC are considered a packaged service. This means that the payment to the facility for these services is included in the payment for the primary procedure.