Ob-Gyn Coding Alert

Question: A physician uses a handheld ultrasound device (such as SonoSite). He is able to meet all the requirements that are required and download the images, thus creating a report. What should we report?

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Answer: Per the May 2009 CPT^® Assistant: "The assignment of the appropriate ultrasound code is based on the type of study performed, not the type of equipment used to perform the study or the indication for the study." Based on this, if there is a recorded image with measurements, an evaluation of organs or anatomic regions, image documentation, and a final written report, you may bill the hand-held ultrasound just as you would if you had not used a portable device (76801-76828, Diagnostic ultrasound procedures of the pelvis obstetrical ...). You should base it on the type of exam performed and documented (e.g., limited or complete). If any of these required elements are missing, the examination is not separately reported and would be considered part of any E/M service. But remember that there will be some levels of ultrasound that cannot be performed with a hand-held unit, such as a detailed ultrasound (76811).