Radiology Coding Alert

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. “The rendering provider is necessary to bill the procedure correctly,” says Christy Hembree, CPC, Team Leader, Summit Radiology Services, Dallas, TX. “Based on where the imaging was performed and who owns the equipment, the code may need a modifier appended to indicate billing for the professional component only.”

4. Image Retention — Appropriate image(s) of the relevant anatomy and/or pathology must be permanently stored and available for future review.