Radiology Coding Alert

Justify medical necessity to build rational claims; check if modifier 26 applies.

Ultrasounds may be one of the most frequent services you may report. You can earn for every evaluation if you remember the basic norms that apply in most situations. Here is a refresher for understanding how well are you earning your deserved payment for ultrasounds. 

Getting started: For diagnostic ultrasound codes, look in the radiology section of the CPT® book for most of the codes, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a medical coding and billing company in Bedford, Mass. The codes are organized by anatomic area with greater specificity of organs or structures visualized, grouped by specific study. Look specifically at 76506-76999. 

Keep in mind some of the ultrasound codes are in the 90000 Medicine section of CPT®. For instance, check 93303-93355 for echocardiography, which refers to ultrasound of the heart, and 93880-93998 for noninvasive vascular studies. The latter group includes terms like doppler and duplex, both of which refer to types of ultrasounds.

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 providers are over utilizing imaging in general and ultrasound in particular based on significant increases in reporting volume. Be sure your claim includes the diagnosis or symptoms that indicated the need for the ultrasound study.

2. Interpretation: The patient’s medical record must include a written interpretation and report. 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: Store and keep available for review appropriate images of the relevant anatomy and/or pathology.

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, consider 76700 (Ultrasound, abdominal, real time with image documentation; complete). 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 include the reason that the provider can’t visualize an element, such as when the gall bladder has been previously surgically removed and is not present for a complete abdominal exam. If documentation shows less than all the required elements for a “complete” exam, you should use the “limited” code for that anatomic region instead, says Granovsky. Code 76705 (… limited [e.g., single organ, quadrant, follow-up]) would be your option for a limited abdominal exam.

Bottom line: To code an ultrasound study separately, there must be a thorough evaluation of organs or anatomic regions, image documentation, and a final written report. 

Remember to Check for Modifier 26

For services performed in a facility, the physician, if submitting his own bill, would typically report the interpretation with modifier 26 (Professional component). 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.

Capture MDM Points for E/M with Ultrasound

Facility policies may require a radiologist to do interpretations and the ultrasound may be needed to contribute to the overall medical decision making (MDM) for an E/M code. Ordering a test and the direct visualization of the study can add points in the amount and complexity of data reviewed section, which counts toward the overall MDM score.