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Ultrasound FAQs

FAQ 1.  What is the appropriate code for the FAST exam?

There is no specific CPT-defined code for the usual clinical FAST exam. Rather, the exam is reportable as two distinct limited ultrasound examinations, when the requirements of both are performed:

  • One component of the exam is the limited transthoracic echocardiogram (93308).
  • The other component of the exam is the limited abdominal ultrasound (76705).

FAQ 2.  What is the difference between a ‘limited’ ultrasound exam and a ‘complete’ ultrasound exam?

A complete ultrasound exam is one that attempts to visualize and diagnostically evaluate all of the major structures within the anatomic region. For example, 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 including any demonstrated abdominal abnormality.

Many emergency department ultrasounds are more focused than "complete." As defined by CPT, a limited ultrasound exam is one in which less than the required elements for a complete exam are performed and documented. Given the nature of the focused ED ultrasound examinations, the limited codes are typically the most accurate for utilization in the ED setting. For example, an abdominal ultrasound used to evaluate the presence of an abdominal aortic aneurysm would be reported as a "limited retroperitoneal ultrasound" (76775).

The one common exception to the rule is the transvaginal ultrasound in the pregnant (76817) and non-pregnant (76830) patient, where there is no corresponding limited procedure CPT.

FAQ 3.  What CPT modifiers are commonly used in coding emergency department ultrasound examinations?

The most common modifier used with ultrasound is probably the -26 Professional Component modifier.

Ultrasound codes are combined, or "global," service codes that include both the technical component and the professional component. In the emergency department setting, the hospital will typically report the technical component that covers the cost of equipment, supplies, and personnel necessary for performing the service. The professional component is reported by the physician for the interpretation of the ultrasound and documentation of the results.

There is nothing in CPT that prohibits the practitioner from also reporting the technical component (TC), if he/she provides all of the necessary elements. However, some payers with which the practitioner participates might have policies prohibiting payment of the TC to practitioners. For example, Medicare will not pay the technical component to hospital-based (but non-hospital-employed practitioners), even if the practitioners own the equipment, provide the supplies, and their personnel perform the technical service.

Also, modifiers -76 and -77 (repeat procedure or service) possibly used in the setting of repeat scans as patients deteriorate (e.g., AAA), or planned serial exams (e.g., FAST).

Some emergency physician practices have contemplated purchasing their own ultrasound machines and billing for the global (professional plus technical) service. Physicians considering this option are well advised to seek legal counsel given the compliance complexities of these kinds of business relationships.

FAQ 4.  What documentation is necessary for the coding of emergency department ultrasound examinations?

For each ultrasound service performed/coded, the following is necessary:

  • Interpretation – a written interpretation and report must be completed and be maintained in the patient’s medical record. The report must describe the structures or organs studied and supply an interpretation of the findings.
  • Medical necessity – the medical record documentation must indicate why the test was medically necessary.
  • Image Retention – appropriate image(s) with measurements when clinically indicated of the relevant anatomy / pathology must be permanently stored and available for future review. Please note that an image is now required for all procedures performed with an ultrasound.

In April 2011, the Office of Inspector General (OIG) reported on “Medicare Payments for Diagnostic Radiology Services in Emergency Departments”.  In summary, providers play a vital role when completing the documentation to support claims for payment for Diagnostic Radiology Services.  The key elements of the medical record documentation should include (1) physician’s orders to support diagnostic radiology services performed and (2) complete interpretation and reports.  In doing the review, the OIG used the American College of Radiology’s (ACR) suggested documentation practice guidelines as a guidance document during the review.  They can be found on the ACR website.  In summary, the ACR recommends the report of radiology services include:

  1. Demographics (facility name, patient name, date and time of exam, etc.)
  2. Relevant clinical information
  3. Body of report (description of study, findings, limitations, etc.)
  4. Impression (diff dx, diagnosis, additional studies recommended, adverse reactions, etc.)

Additional Recommendations:

  • The report should identify who performed the procedure and who interpreted the procedure.
  • The scope of the study should be described including whether the study was complete or limited, a repeat examination by the same physician, a repeat examination by a second physician, and/or a reduced level of service.

FAQ 5.  Does the patient’s pregnancy status matter when coding for a transabdominal or transvaginal ultrasound?

Yes.  The pregnancy status of the patient and the purpose of the ultrasound examination determine the proper code.

  • Transabdominal ultrasound:
  • When the patient is known to be pregnant and the physician is utilizing ultrasound to evaluate the pregnancy or a suspected complication of, or to the pregnancy, then the obstetric pelvic code should be used (76815).
  • When the patient is not pregnant, or the status of the pregnancy is unknown prior to the examination, and the ultrasound is used to evaluate pelvic pain, amenorrhea, vaginal bleeding or non-gynecologic pelvic pathology, then the non-obstetric code should be used (76857).
  • Transvaginal ultrasound
  • Prior to 2004 there was a single code for transvaginal ultrasound that did not differentiate between pregnant and non-pregnant patients. Now, there are two codes depending on the pregnancy status.
  • If the patient is pregnant use code (76817).
  • If the patient is NOT pregnant use code (76830).
  • It is important to note that there is only a complete exam code for transvaginal ultrasound. Many emergency department transvaginal ultrasounds are less than complete exams, thus it is appropriate to use the modifier -52 Reduced Services.

Example: pregnant transvaginal ultrasound, professional service only (76817-26, -52).

FAQ 6.  I use ultrasound frequently for placing central lines. What are the requirements for billing for the ultrasound?

Code (76937) is used specifically for central venous access with ultrasound guidance. The current CPT description is:

"Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting."

There are several unique aspects of the central venous and peripheral vascular access with ultrasound guidance code of which users must be aware. The first is that the code is intended for use only when the ultrasound is used with the "dynamic" technique, as opposed to the "static" technique which is not considered a reimbursable service.

The static technique utilizes the ultrasound to identify the vessel, but is not used during line placement. In the dynamic technique the physician uses the ultrasound throughout the procedure from initial identification of the vessel through direct visualization of the needle entering the vessel. A permanently recorded image is required for coding.

When coding a central line placement under direct dynamic visualization with ultrasound it is appropriate to code 76937 for vascular ultrasound guidance and 36556 for the adult central venous line placement.

FAQ 7.  If I use the ultrasound to aid in a procedure, do I code for both the ultrasound and the procedure?

Generally, it is appropriate to code for both the ultrasound guidance and the procedure performed. For example when performing an I&D of an abscess with ultrasound assistance, both the I&D 10060 and the ultrasound guidance for needle placement 76942-could be coded.

FAQ 8.  Do I need to store an ultrasound image to be able to code for the exam?

In the past, the requirement for image retention was a point of discussion. As of 2005, CPT clearly states that image retention is mandatory for all diagnostic and procedure guidance ultrasounds.

CPT does not specify how the images are to be stored or how many images are required. Appropriate image(s) demonstrating relevant anatomy/pathology for each procedure coded should be retained and available for review.

FAQ 9.  What are the most commonly used emergency department ultrasound CPTs?

Primary Indications:

Trauma Ultrasound – Thoracoabdominal Trauma (FAST Exam)
Ultrasound, abdominal, real time with image documentation limited (e.g., single organ, quadrant, follow-up) 76705 (-26)
Plus, +

Echocardiography, transthoracic, real-time with image documentation (2D) includes M-Mode recording, follow-up or limited study

*(for non-traumatic hemoperitoneum or ascites use 76705)

93308 (-26)
Abdominal Aortic Aneurysm
Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; limited 76775 (-26)
Pericardial Fluid
Echocardiography, transthoracic, real-time with image documentation (2D), includes M-Mode recording, follow-up or limited study 93308 (-26)

Transabdominal and Transvaginal Ultrasound with or without Pregnancy

Transabdominal

Pregnancy known prior to examination and ultrasound is utilized for evaluation of the pregnancy or a pregnancy related condition

Ultrasound, pregnant uterus, real time with image documentation; limited (e.g., fetal heartbeat, placental location, fetal position and/or qualitative amniotic fluid volume), one or more fetuses.

76815 (-26)
Or,

Pregnancy NOT known prior to examination, or ultrasound is utilized for a non-pregnancy related pelvic evaluation

Ultrasound, pelvic (non-obstetric), real time with image documentation; limited or follow-up (e.g., for follicles)

76857 (-26)

Plus/Or,

Transvaginal*
Ultrasound, pregnant uterus, real time with image documentation, transvaginal 76817 (-52) (-26)
Or,

NOT pregnant, non-obstetric transvaginal ultrasound

*may be used as sole code or with 76815 or 76857

76830 (-52) (-26)
Evaluation of Renal Disease
Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; limited 76775 (-26)
Evaluation of Biliary Tract Disease
Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant, follow-up) 76705 (-26)

Ultrasound procedure guidance

 Ultrasound guidance for pericardiocentesis
Ultrasonic guidance for pericardiocentesis, imaging supervision and interpretation 76930 (-26)

Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure)

76937 (-26)

Ultrasound guidance for needle placement - use for paracentesis, thoracentesis, suprapubic aspiration, location of abscess for drainage (e.g., peritonsillar abscess) Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) imaging supervision and interpretation

(Do not use 76937 in conjunction with 76942)

76942 (-26)

 

FAQ 10.  Can an emergency physician code for a limited examination if the patient also gets a complete examination performed by another medical specialist on the same date?

It is generally allowable under CPT for two different physicians (e.g., two different medical specialists) to report a limited and a complete exam of the same anatomic description at different exam sessions, on the same date of service, if the medical record supports the medical necessity of the two separate procedures.

For example, on some occasions an initial limited examination by an emergency physician will be inconclusive or demonstrate an unexpected finding requiring a complete examination, or a follow-up examination by another medical specialist. It is required that each examination, limited or complete, stand on its own merit as a medically necessary study. It is important to document in the medical record why the repeat or follow-up study was required.

It is not permissible however, for the same physician to code for a limited exam followed by a complete exam of the same anatomic region in the same exam session. In this case, the limited exam is viewed as being included or "bundled" in the more comprehensive complete service.

When coding for a limited and complete exam by two different practitioners, the use of the -77 modifier "Repeat Procedure by another physician" by the second medical specialist might assist in justifying payment for both studies.

It is important to note however that some payers might recognize only the more complete examination and therefore pay for the complete study only, denying payment for the limited evaluation procedure done by the emergency physician.

FAQ 11.  Can I code for serial ultrasounds?

It may be clinically necessary for the same physician to conduct multiple examinations if significant interval changes have occurred or are suspected. When coding the repeat exam, it is appropriate to then use the -76 modifier "Repeat procedure by same physician."

It is important to note however that CPT states in its general instructions that "…the ‘limited’ code for that anatomic region should be used once per patient exam session." Serial examinations over different exam sessions can be coded, but be sure that the medical record clearly demonstrates the medical necessity for each subsequent exam, in order to address the expected payer denials.

FAQ 12.  Do I need to be credentialed by the hospital to code for an emergency department ultrasound?

CPT clearly identifies the requirements for complete and limited ultrasound services. CPT does not specifically require an emergency physician to be credentialed by a hospital or a specialty society for the provision of these services.

 In order to provide interpretive services in a given location or hospital, however, local medical bylaws might limit access to the equipment necessary to perform the services, or state law and/or contractual agreements might otherwise limit a physician’s ability to provide or report the service.

For additional information regarding Emergency Department US services, see the Ultrasound section of Practice Resources on the ACEP Web site.

The code is based on the location of the abnormality.

The following codes would be reported for the specific site. 

Neck 76536
Upper Extremity 76882
Axilla 76882
Chest Wall 76604
Upper Back 76604
Lower Back 76705
Abdominal Wall 76705
Pelvic Wall 76857
Buttock 76857
Groin 76870
Perineum 76857
Lower Extremity 76882
Other Soft Tissue 76999

 

 

 

 

 

 

 

 

Last Updated 04/2014

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