Radiology Coding Alert

Know where to look for nationally non-covered ultrasound services.

When you report diagnostic ultrasound, be sure to check three main resources. Here are the can't-miss rules from Medicare's National Coverage Determinations (NCDs) Manual and CPT® guidelines, with a look at local coverage determinations (LCDs), too.

NCD: Discover Covered Services in the Diagnostic Ultrasound NCD

If you provide diagnostic ultrasound services to Medicare patients, take time to review section 220.5 of the NCD manual, "Ultrasound Diagnostic Procedures" (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf). The NCD describes covered and non-covered services.

Covered: The diagnostic ultrasound NCD lists dozens of nationally covered indications, which it refers to as Category I. For example, indications in the list include echocardiography, Doppler peripheral arterial flow study, and renal biopsy by ultrasonic guidance.

Non-covered: There's also a section for nationally non-covered indications called Category II. "Techniques in Category II are considered experimental and should not be covered at this time," the NCD states. The nationally non-covered list is very short: "B-Scan for atherosclerotic narrowing of peripheral arteries."

Not listed? If your physician uses ultrasound for an indication not listed in the NCD, you should check your local payer policy. The NCD states, "uses for ultrasound diagnostic procedures not listed in Category I or II above are left to local contractor discretion." And there could be many services not listed in the NCD considering that ultrasound is "widely employed to determine the composition and contours of nearly all body tissues except bone and air-filled spaces."

NCD Bonus: Look Beyond the Main Policy

Ultrasound is mentioned in the NCD manual outside of the main diagnostic ultrasound NCD. When you're researching ultrasound coverage, check whether the specific service you're looking into has its own NCD.

Diagnostic examples: The diagnostic ultrasound NCD includes a cross reference to section 20.17, "Noninvasive Tests of Carotid Function." The reason is that section 20.17 includes a non-exhaustive list of acceptable tests to measure carotid function. The list includes Doppler flow velocity and ultrasound imaging including real time.

Not every ultrasound NCD is cross-referenced, however. For instance, ultrasound also comes up as a diagnostic approach in the NCD for percutaneous transluminal angioplasty (PTA) (section 20.7): "The degree of carotid artery stenosis shall be measured by duplex Doppler ultrasound or carotid artery angiography and recorded in the patient's medical records. If the stenosis is measured by ultrasound prior to the procedure, then the degree of stenosis must be confirmed by angiography at the start of the procedure. If the stenosis is determined to be < 70 % by angiography, then CAS should not proceed."

Guidance example: In some cases, NCDs may indicate that ultrasound guidance is allowed for certain covered services. Consider this excerpt from the NCD for percutaneous image-guided breast biopsy (section 220.13): "Percutaneous image-guided breast biopsy is a method of obtaining a breast biopsy through a percutaneous incision by employing image guidance systems. Image guidance systems may be either ultrasound or stereotactic."

Therapeutic example: In addition to diagnostic ultrasound and ultrasound guidance, the NCD manual includes information on therapeutic ultrasound. In particular, the NCD for treatment of kidney stones (section 230.1) states, "Percutaneous lithotripsy of kidney stones by ultrasound or by the related techniques of electrohydraulic or mechanical lithotripsy is covered under Medicare."

LCD: Confirm Added Details With Local Payer

As mentioned above, the diagnostic ultrasound NCD states that uses not listed in the NCD are left to local contractor discretion. That means you need to check your Medicare administrative contractor's (MAC's) LCDs to get complete coverage information.

Spine example: Florida MAC First Coast Service Options specifies coverage indications and limitations for 76800 (Ultrasound, spinal canal and contents) in LCD L30353. For adults, FCSO considers spine ultrasound medically necessary only when used intra-operatively. In contrast, the service may be medically necessary "for the newborn and infant in the diagnostic evaluation of the spinal cord and canal." As a result, FCSO has a coding guideline that "all place of service (POS) locations, other than operating room in a hospital, are limited to ages from birth to twenty-four months old."

Abdominal example: LCDs may also expand on ultrasound uses mentioned in the NCD. For instance, the NCD includes retroperitoneal and limited and complete abdominal studies in the list of covered services. Colorado MAC Trailblazer's LCD L26750 includes indications and limitations of coverage as well as coding information specific to abdominal and retroperitoneal ultrasounds. So if you want to confirm that Trailblazer will cover an abdominal study (76700, Ultrasound, abdominal, real time with image documentation; complete) for a diagnosis of 574.00 (Calculus of gallbladder with acute cholecystitis without obstruction), you can check the LCD.

CPT®: Comply With Documentation Guidelines

To take your diagnostic ultrasound coding and coverage knowledge to the next level, you have to have a firm grasp on CPT® guidelines. While you should review the guidelines for each individual ultrasound subsection, there are four main pointers to keep in mind that apply overall and are summed up in this CPT® quote: "Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable."

1. Permanent recorded image: Diagnostic ultrasounds require permanently recorded images that include any clinically indicated measurements, noted Cheryl A. Schad, BA Ed, CPC, ACS-RA, PCS, of Schad Medical Management in "Understanding the Intricacies of Ultrasound Coding" (AudioEducator.com). Ultrasound guidance also requires permanently recorded images.

Exception: If the goal of a service is a biometric measure, CPT® states that permanently recorded images aren't required, added Schad.

2. Report: The patient's medical record must include a written report detailing the diagnostic ultrasound service. Ultrasound guidance procedures similarly require a documented description. The description can be separate, but it's also OK for the guidance description to be in the same report as the main procedure.

3. Complete vs. limited: Some ultrasound codes may cover the same anatomic area but vary based on whether the exam is limited or complete. To qualify as complete, the radiologist's report should describe all of the elements that comprise a complete exam. If he can't visualize one or more of the elements, you still can code a complete exam if he documents why he couldn't visualize the element(s). CPT® provides the examples of "surgically absent" or "obscured by bowel gas." If documentation doesn't meet the requirements for a complete exam, then you should report a single unit of the limited exam code. You shouldn't report limited and complete exams for the same region.

4. Doppler: CPT® states that you should not report color Doppler alone when the provider uses it to identify anatomic structures during real-time ultrasound. On the other hand, "evaluation of vascular structures using both color and spectral Doppler is separately reportable" using 93880-93990. To support reporting both to Medicare, be sure you have an order for the addition of color Doppler with spectral analysis, Schad advised.