Radiology Coding Alert

You may need to code ultrasound more frequently in your office settings.

Ultrasonography is a basic and initial approach to establishing a diagnosis, so you need to make certain you understand how to report these services. Besides being able to target the right code, you need to have the skills to document the findings of the investigation and maintain archives for the images. Above all, don’t forget to check with payers for policies regarding the conduct of the test and interpretation of the sonological results.

Refresher: In ultrasound or sonography, images are made by sending pulses of ultrasound waves into tissue using a probe. The sound echoes off the tissue or areas being scanned and are then imaged and recorded.

The CPT^® manual offers a wide range of codes for ultrasound that are similar to traditional X-ray codes. So beware! Analogic ultrasound codes make no guarantees concerning reimbursement or coverage. It is the responsibility of the provider to determine and submit appropriate codes, modifiers, and claims for services rendered.

Document the Images and Record Everything

You need to maintain the written reports of all ultrasound studies in the patient’s record. This report should be detailed enough to support the choice of codes for a procedure. For example, below are two codes for ultrasound of the extremities:

• 76881, Ultrasound, extremity, nonvascular, real-time with image documentation; complete
• 76882, ... limited, anatomic specific.

When submitting codes 76881 and 76882, you need to ensure that there is documentation to support what structures were assessed during the ultrasound. CPT^® guidelines instruct that complete code 76881 includes real time ultrasound scans of a joint. Documentation for a complete ultrasound should reference related “muscles, tendons, joint, other soft tissue structures, and any identifiable abnormality.”

On the other hand, limited study code 76882 applies to the examination of a specific anatomic structure, including a muscle, tendon, joint, or other soft tissue. For example, you may see a limited exam for an Achilles tendon injury.

Code 76882 also is appropriate for a soft-tissue mass evaluation. In this case, your physician may be investigating the mass to explore its cystic or solid characteristics.

How to record? You may adopt either of the following ways to record:

• For ultrasound guidance procedures, the written reports may be filed as a separate item in the patient’s record or included within the report of the procedure for which the guidance is used.
• You can store records as printed images or on a tape or electronic medium that’s kept in the patient record or some other archive (they are not required to be submitted with the claim). You may have to produce these documents if the insurer requests you to do so.

Most of the ultrasound codes are inclusive of image documentation. This is also clearly stated in the code descriptors. Below are some examples:

• 76536, Ultrasound, soft tissues of head and neck (e.g., thyroid, parathyroid, parotid), real time with image documentation
• 76604, Ultrasound, chest (includes mediastinum), real time with image documentation
• 76641, Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete
• 76700, Ultrasound, abdominal, real time with image documentation; complete
• 76776, Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation
• 76881, Ultrasound, extremity, nonvascular, real-time with image documentation; complete

Understand the Payer’s Payment Policies

Medicare Part B will reimburse physicians for medically necessary diagnostic ultrasound services, provided the services are within the scope of the physician’s license. Some Medicare carriers require the physician who performs and/or interprets some types of ultrasound examinations to demonstrate relevant, documented training through recent residency training or post-graduate CME and experience. You should contact your Medicare Part B Carrier for details.

Private insurance payment rules about which specialties may perform and receive reimbursement for ultrasound services vary by payer and plan. Some payers will reimburse providers of any specialty for ultrasound services while others may restrict imaging procedures to specific specialties or providers possessing specific certifications or accreditations. Some insurers require physicians to submit applications requesting ultrasound exams and procedures be added to their list of services performed in their practice.

Note: It is important to contact your private payers before submitting claims to determine their requirements and request that they add ultrasound to your list of services.