Radiology Coding Alert

Question: A patient presented to the emergency department (ED) with left knee pain. The hospital’s radiology department performed an ultrasound of the patient’s knee to evaluate for fluid collection. The ED physician reviewed the images and issued negative findings for fluid collection. I’m trying to bill for the profee charge, not the provider’s evaluation and management (E/M) charge.

Should I assign 76882 or an unlisted code for the ultrasound professional fee? Also, what does “with image documentation” mean?

Wyoming Subscriber

Answer: You’ll assign 76882 (Ultrasound, limited, joint or focal evaluation of other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft-tissue structure[s], or soft-tissue mass[es]), real-time with image documentation) appended with modifier 26 (Professional component) to report the profee charge for the knee ultrasound.

Even though the ED provider found the patient’s knee unremarkable, the patient’s record or the radiology picture archiving system (PACS) needs to include images of the knee to complete the documentation. That is what “with image documentation” means in 76882’s descriptor. Regardless of whether the radiology department saves images, or the ED provider uses a point-of-care ultrasound (POCUS), captures screenshots of the monitor, and transfers those images to the hospital PACS, someone needs to save images as part of the documentation.

If no picture is available, then the documentation is incomplete, and you’ll likely face a claim denial.