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Medicare Compliance & Reimbursement

Ultrasound Billing:

Probe Carefully to Ethically Maximize Ultrasound Reimbursement

Published on Sun Oct 17, 2010

Diagnostic imaging services are under increased payer scrutiny.

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.

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 they should 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 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 success 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.

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