Radiology Coding Alert

Report medical necessity and check extent of scan.

When your radiologist provides ultrasound diagnostic services in the emergency department, you’ll need to be specific for the medical necessity of the service. Make sure you appropriately record the interpretation of the scan to earn for the service in the E/D setting.

Getting started: CPT^® offers discrete options for diagnostic ultrasound codes. You look in the radiology section of the CPT^® book for codes 76506 through 76999. The codes are organized by anatomic area with greater specificity of organs or structures visualized, grouped by specific study. (See ‘Check These 4 CPT^® Requirements for Ultrasound’ for common ED ultrasound procedures).

Distinguish 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 Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a medical coding and billing company in Bedford, MA.

As an example, the CPT^® language in the introduction to the abdominal and retroperitoneum ultrasound section reads as follows ‘A complete abdominal ultrasound would consist of real time scans of the: liver, gall bladder, common bile duct, pancreas, spleen, kidneys, upper abdominal aorta and inferior vena cava.’ You report code 76700 (Ultrasound, abdominal, real time with image documentation; complete) for a complete abdominal ultrasound.

In this case: The report should contain a description of all the listed elements or the reason that an element could not be visualized, such as when the gall bladder has been previously surgically removed and not present for a complete abdominal exam. If less than all the required elements for a ‘complete’ exam are reported, as when a limited number of organs or a limited portion of the region evaluated is visualized or documented, the ‘limited’ code for that anatomic region should be used instead, says Granovsky. “If the documentation does not contain all of the required elements, a limited study must be assigned,” says Hembree. “A limited ultrasound abdomen may be performed to look at a single organ or quadrant.” For limited ultrasound of abdomen, you report 76705 (Ultrasound, abdominal, real time with image documentation; limited [e.g., single organ, quadrant, follow-up]).

All ultrasound diagnostic examinations require recorded images with measurements when such measurements are clinically indicated, advises Granovsky. In order for an ultrasound study to be separately coded, there must be a thorough evaluation of organ(s) or anatomic regions, image documentation, and a final, written report. Without all of these elements, the examination is not separately reported and would be considered part of any Evaluation and Management service which occurred during that session.

For services performed in a facility, the radiologist would typically report the interpretation with modifier 26 (Professional component). Even if the physician personally performs the ultrasound rather than a tech, use of the code without a modifier may not be appropriate as the facility has provided the room and most likely the equipment, Granovsky adds.

Be Aware of These Barriers to Successful Ultrasound Reporting

Your emergency physician group may perform ultrasound testing but may not separately bill for those procedures due to several recurring factors. A recent survey by the American College of Emergency Physicians (ACEP) Ultrasound Section lists these potential barriers to successfully reporting ultrasound which include failure to archive the required images, document the full report, or low reimbursement costs.

“Many emergency department ultrasounds are more focused or FAST (focused assessment by sonography for trauma) which means most coders will end up coding a limited ultrasound vs. a complete for the ED setting,” says Hembree.

Capture MDM Points for E/M with Ultrasound

The ultrasound that your radiologist does in the E/M setting may contribute to the overall medical decision making (MDM). Your radiologist’s report can help to formulate a specific treatment plan. Direct visualization of the study can add points in the amount and complexity of data reviewed section, which are counted towards the overall MDM score.

Consider these coding examples from Granovsky:

Example 1: A 35-year-old male drives into a tree at 30 miles per hour. His vital signs are stable but he then becomes tachycardic and complains of abdominal pain. He experiences no loss of consciousness but complains of neck pain.

The work up included a physical exam, a C-spine x-ray series, lab work, and a focused assessment with sonography in trauma (FAST) exam with documentation of direct visualization of the images for the abdominal and cardiac components of the FAST.

According to a typical Marshfield Clinic Score Sheet grid, you have supported one of the requirements for high complexity MDM by scoring a total of four data points:

• 1 point for ordering the C spine X ray
• 1 point for review of the lab work,
• And with addition of the ultrasound study, 2 points for the independent visualization of the ultrasound images.

Example 2: A 55-year-old male presents with a painfully red swollen area on the right lower leg. He has a history of insulin dependent diabetes and a pulse of 102 with a low grade fever.

The clinical course includes a CBC, an order for the old records, as well as ordering an ultrasound exam of the lower extremity to evaluate for the presence of an abscess.

According to a typical Marshfield Clinic-type scoring grid, you might score the following with regard to amount and complexity of data reviewed:

• 1 point for ordering for a clinical lab test (CBC)
• 1 point for decision to obtain old records (the ultrasound)
• 1 point order of a radiology study

You have now supported 1 area of moderate complexity medical decision making.

Example 3: A 25-year-old male presents to the ED following a rollover motor vehicle accident. Vitals are as follows:

BP 80’s, HR 120, Belly firm. The physician is concerned about a ruptured spleen and performs a FAST exam evaluating both the abdomen and the pericardial area. Documentation of both the abdominal and cardiac components are present in the record.

The following ultrasound codes would be reported:

• 76705 (Ultrasound, abdominal, real time with image documentation; limited) (e.g., single organ, quadrant, follow-up)
• 93308 (Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study).