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Ultrasound FAQ

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

There is no single CPT-defined code for the clinical FAST exam. Instead, the exam is reportable as either two or three distinct limited ultrasound examinations when the requirements for these codes are performed:

  1. The cardiac component of the exam is reported with the CPT code for a limited transthoracic echocardiogram (93308).   
  2. The abdominal component of the exam is reported with the CPT code for limited abdominal ultrasound (76705).   
  3. The thoracic component (e.g., hemothorax or pneumothorax evaluation, if performed) of the exam is reported with the CPT code for limited chest ultrasound (76604).

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, gallbladder, common bile duct, pancreas, spleen, kidneys, upper abdominal aorta, and inferior vena cava, including any demonstrated abdominal abnormality.

Most diagnostic 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, for which there is no corresponding limited procedure CPT.  In these cases, a -52 modifier, which is a service reduction modifier, should be included to indicate that the ultrasound is less than a complete study.

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

Ultrasound codes are combined, or “global,” service codes that include both the technical component (TC) and the professional component (notated by modifier -26). 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 clinician reports the professional component for the ultrasound interpretation and documentation of the results with the -26 Professional Component modifier. Modifier -26 is probably the most common modifier used with ultrasound.

Nothing in CPT prohibits practitioners from reporting the technical component (TC) if they provide all 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 performs the technical service.

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

As stated above in FAQ 2, a -52 modifier, which is a service reduction modifier, should be included in cases in which no limited CPT exists but the performed ultrasound is less than a complete study (e.g., transvaginal ultrasound in the pregnant (76817) and non-pregnant (76830) patient).

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

Modifier

Description

Example

-26

Professional Component modifier

Used to signify that only professional component is being billed

-76

Repeat procedure or service by SAME clinician

Repeat AAA ultrasound after patient deteriorates.

 

Planned repeat FAST scan.

-77

Repeat procedure or service by DIFFERENT clinician

Repeat AAA ultrasound after patient deteriorates.

 

Planned repeat FAST scan.

-52

Service reduction modifier

Transvaginal pelvic ultrasound in pregnant or non-pregnant patient

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

For each diagnostic ultrasound service performed/coded (even if limited or focused), the following is necessary:

  1. Interpretation– a written interpretation and report must be completed and maintained in the patient’s medical record. The report must describe the structures or organs studied and provide an interpretation of the findings.
  2. Medical necessity– the medical record documentation must indicate why the test was medically necessary (study indications).   
  3. 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.   

For consideration for Medicare patients, 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. Clinician’s orders to support diagnostic radiology services performed
  2. Complete interpretation and reports

During the review, the OIG used the American College of Radiology’s (ACR) suggested documentation practice guidelines as a guidance document. They can be found on the ACR website

In summary, the ACR recommends that reports of radiology services include the following:

  1. Demographics (facility name, patient name, exam date and time, 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.)   

The ACEP Ultrasound Section provides Emergency Ultrasound Standard Reporting Guidelines. These guidelines include documentation above and beyond what is required for coding. The core recommendations for documentation are to provide

  1. Patient demographics
  2. An indication for the exam
  3. Views
  4. Findings
  5. Interpretation
  6. Quality assurance

Additional Recommendations:

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

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

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

Transabdominal ultrasound:

  • When the patient is known to be pregnant, and the clinician 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 pregnancy status 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

  • 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 a transvaginal ultrasound. Many emergency department transvaginal ultrasounds are limited exams; thus, using the modifier -52 Reduced Services in these cases is appropriate.   
  • Example: pregnant transvaginal ultrasound, professional service only (76817-26, -52).

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

Code (76937) is explicitly used for vascular access with ultrasound guidance. The current CPT description is as follows:

  • "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." This is an add-on procedure, so it is added to the primary code for billing.
  • There are several unique aspects of 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 clinician 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. Of note, the CPT description is interpreted as requiring an image of the target vessel, but not necessarily an image of the needle in the vessel as it enters. It is believed that obtaining an image of the needle as it is entering the vessel poses unacceptable risks to the patient, as it would require the solo operator to take their attention away from the procedure in order to obtain an image. It is recommended that permanent recording of the selected vessel or the needle in the vessel, when feasible and safe, while using a procedure note to document the procedure, was performed with concurrent real-time visualization.  While a still image of the target vessel prior to successful cannulation is acceptable, a post-procedural still image of the catheter in the vessel, once the line is secure, is preferable.

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 CPT code, e.g., 10060, and the ultrasound guidance for needle placement 76942 could be coded.  Documentation requirements for coding ultrasound guidance differ from diagnostic ultrasound requirements (see page 16, CPT Assistant August 2021, for a clinical example of documentation requirements for ultrasound guidance procedures).

However, several codes have evolved over the last few years to include the ultrasound in the performance of the procedure (e.g., knee arthrocentesis with ultrasound guidance, 20611).

The following are ED-relevant procedures where imaging guidance is included, and the ultrasound cannot be reported separately.

  • Thoracentesis (32555)
  • Paracentesis (49083)
  • Arthrocentesis (20604, 20606, 20611)
  • Introduction/Injection of Anesthetic Agent aka Nerve Block or Digital Block (NEW for 2023) (64415, 64416, 64417, 64445, 64446, 64447, 64448, 64451, 64454)

These procedures are frequently performed with imaging guidance, but the ultrasound is not included and can be reported separately.

  • Incision and Drainage Subcutaneous (10060, 10061)
  • Puncture Aspiration (10160)
  • Incision and Foreign Body Removal (10120, 10121)
  • Pericardiocentesis (33010)
  • Central Venous Catheter Insertion (36555, 36556)
  • Drainage of Tonsil or Peritonsillar Abscess (42700)
  • Aspiration of Bladder by Needle (51100)
  • Diagnostic Lumbar Puncture (62270)
  • Introduction/Injection of Anesthetic Agent aka Nerve Block or Digital Block (64400, 64405, 64408, 64420, 64421, 64425, 64430, 64435, 64449, 64450)

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

In the past, the image retention requirement was a discussion point. 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.

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

Trauma FAST/EFAST

CPT Code

Common Modifier(s)

CPT Description

2023 wRVU

76705

-26

Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant, follow-up)

0.59

93308

-26

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

0.53

76604

-26

Ultrasound, chest (includes mediastinum), real time with image documentation

0.59

AAA Ultrasound

CPT Code

Common Modifier(s)

CPT Description

2023 wRVU

76775

-26

Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; limited

0.58

Limited Echocardiography

CPT Code

Common Modifier(s)

CPT Description

2023 wRVU

93308

-26

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

0.53

Pelvic Ultrasound in Pregnant Patient

CPT Code

Common Modifier(s)

CPT Description

2023 wRVU

76815

-52, -26

Ultrasound, pregnant uterus, real time with image documentation, limited (e.g., fetal heart2.beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses

0.65

76817

-52, -26

Ultrasound, pregnant uterus, real time with image documentation, transvaginal

0.75

Ultrasound Evaluation for Renal Disease

CPT Code

Common Modifier(s)

CPT Description

2023 wRVU

76775

-26

Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; limited

0.58

Biliary Ultrasound

CPT Code

Common Modifier(s)

CPT Description

2023 wRVU

76705

-26

Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant, follow-up)

0.59

Ophthalmic Ultrasound

CPT Code

Common Modifier(s)

CPT Description

2023 wRVU

76512

-26

Ophthalmic ultrasound, diagnostic; B-scan (with or without superimposed non-quantitative A-scan)

0.56

DVT Ultrasound

CPT Code

Common Modifier(s)

CPT Description

2023 wRVU

93971

-26

Duplex scan of extremity veins, including responses to compression and other maneuvers; unilateral or limited study

0.45

Ultrasound for Procedural Guidance

CPT Code

Common Modifier(s)

CPT Description

2023 wRVU

76937

-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)

0.30

76942

-26

Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation

0.67

49083

-26

Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance

2.00

20611

-26

Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting

1.10

 

10. Can an emergency clinician 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 clinicians (e.g., two different medical specialists) to report a limited and 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 clinician will be inconclusive or demonstrate an unexpected finding requiring a complete examination by another medical specialist. It is required that each examination, limited or complete, stand on its merit as a medically necessary study. It is important to document in the medical record why a repeat or follow-up study was required.

It is not permissible, however, for the same clinician 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 considered included or “bundled” into the more comprehensive, complete service.

When coding for a limited and complete exam by two different practitioners, the -77 modifier "Repeat Procedure by another clinician" 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 clinician.

11. Can I code for serial ultrasounds?

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

CPT, however, 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 to address the expected payer denials.

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 explicitly require an emergency clinician to be credentialed by a hospital or a specialty society to provide these services.

Local medical bylaws may limit access to the equipment necessary to perform the services. State law and/or contractual agreements might otherwise limit a clinician’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 website.

13. Which CPT code is used to report the ultrasound examination of a palpable mass?

The code is based on the location of the abnormality. The following codes would be reported for the specific site.

  1. Neck - 76536   
  2. Upper extremity - 76882   
  3. Axilla - 76882   
  4. Chest wall - 76604   
  5. Upper back - 76604   
  6. Lower back - 76705   
  7. Abdominal wall - 76705   
  8. Pelvic wall - 76857   
  9. Buttock - 76857   
  10. Groin - 76870   
  11. Perineum - 76857   
  12. Lower extremity – 76882   
  13. Other soft tissue – 76999   

It should be noted that CPT 2023 added new parenthetical instructions for CPT code 76882.

Code 76882 represents a limited evaluation of a joint or focal evaluation of a structure(s) in an extremity other than a joint (e.g., soft-tissue mass, fluid collection, or nerve[s]). Limited evaluation of a joint includes assessment of a specific anatomic structure(s) (e.g., joint space only [effusion] or tendon, muscle, and/or other soft-tissue structure[s] that surround the joint) that does not assess all of the required elements included in 76881. Code 76882 also requires permanently recorded images and a written report containing a description of each of the elements evaluated. CPT 2023 pg. 548.

14. Where can I obtain more information regarding ultrasound coding and billing?

The Emergency Ultrasound Section has a number of essential documents which provide a more in-depth discussion of billing and coding topics:

Focused Cardiac Ultrasound in the Emergent Setting (PDF)

Standard Reporting Guidelines: Ultrasound for Procedure Guidance (PDF)

Emergency Ultrasound Standards Reporting Guidelines (PDF)

 

 

Updated April 2023

 

Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.

The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors, or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising from the use of such information or material. Specific coding or payment-related issues should be directed to the payer.

For information about this FAQ/Pearl, or to provide feedback, please contact David A. McKenzie, ACEP Reimbursement Director, at (469) 499-0133 or dmckenzie@acep.org

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