By Sarah Todt, RN, CPC, CPMA, CEDC
Ultrasound technology has evolved with recent changes allowing for these diagnostic studies to be performed at the patient’s bedside. The machines are more portable and affordable than ever, which has led to increased use of services. Many residency programs require training in the performance and interpretation of bedside ultrasounds. Ultrasound services are not limited to radiologists, but may be performed by other specialties, such as emergency physicians and anesthesiologists.
Bedside Ultrasound Defined
Ultrasound is a medical imaging technique using high frequency sound waves and their echoes to create an image for evaluation. Providers may use ultrasound to evaluate the patient for a condition or to assist with a procedure. CPT® codes related to ultrasound are found in the radiology section. The codes are identified by the anatomical location evaluated, or by the diagnostic procedure performed with the assistance of ultrasound.
The anatomical codes are further delineated by the detail amount of the study (complete or limited). A “complete” study represents an attempt to view and evaluate all of the major structures in an anatomical location. For example, a complete abdominal ultrasound (76700 Ultrasound, abdominal, real time with image documentation; complete) would include evaluation of all the major abdominal organs, including the liver, gall bladder, bile duct, spleen, pancreas, kidneys, and major vessels, in addition to any abnormality.
A “limited” study represents a directed evaluation of one or more organs for a suspected condition. For example, a provider performs a limited abdominal study to assess the presence of gallstones. This service would be reported with CPT® code 76705 Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow up).
If a limited ultrasound is performed on an anatomical location for which there is no CPT® code for a limited study, the complete study may be reported with modifier 52 Reduced services to indicate the reduced service. For example, there is no limited study code equivalent of 76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal. To report such a limited study, you would claim 76817-52.
Bedside Ultrasound Indications
Bedside ultrasound may be used in support of another procedure. For instance, ultrasound guidance is frequently used for needle placement and vascular access. Ultrasound guidance used for needle placement for procedures, such as needle biopsy or aspiration or injections, would be reported with CPT® 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation. The ultrasound is used to aid localization with a needle.
Ultrasound guidance for central venous line placement would be reported with +76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure). Ultrasound guidance codes should be reported in addition to the primary procedure. For example, a provider uses ultrasound guidance to place a subclavian central venous line. The central line would be reported 36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older, with +76937.
Bedside ultrasound may also be used to evaluate soft tissue for diagnostic purposes. The codes for these ultrasounds depend on the location of what is being evaluated.
- Evaluation of an extremity (i.e., arm including axilla or leg (non-vascular)) would be reported with 76882 Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific.
- Evaluation of soft tissue of the neck would be reported with 76536 Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation.
- Chest wall and upper back would be reported with 76604 Ultrasound, chest (includes mediastinum), real time with image documentation.
- Lower back and abdominal wall would be reported with 76705.
- Soft tissue areas of the lower abdomen, pelvis, and buttocks would be reported with 76857 Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles).
Bedside ultrasounds are also used for diagnostic evaluations. In the emergency department (ED), providers may perform a Focused Assessment Sonogram for Trauma (FAST) exam to evaluate for traumatic injuries. FAST generally represents two distinct ultrasounds: a limited transthoracic echocardiogram (CPT® 93308 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study) as well as a limited abdominal ultrasound (76705). Documentation requirements must be met for both services to report them.
There are many more indications for bedside ultrasounds for diagnostic purposes. Retroperitoneal ultrasound (76775 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited) would be used when evaluating for abdominal aortic aneurysm or for renal disease. Limited abdominal ultrasound (76705) may be used for the evaluation of biliary tract disease or other abdominal pathology.
Pelvic Ultrasound Depends on Pregnancy Status
Female pelvic and transvaginal ultrasounds code selection depends on whether the patient is known to be pregnant prior to the test. A limited pelvic ultrasound is reported with 76857 if the patient is not known to be pregnant prior to the study. If the patient is known to be pregnant prior to the study, 76815 Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses should be reported.
The transvaginal ultrasound codes for non-pregnant (76830 Ultrasound, transvaginal) and pregnant (76817) uterus do not have a selection for limited study. If you must report a limited study of this type, append modifier 52 to either 76830 or 76817, as appropriate. For example, a provider performs a limited transvaginal ultrasound to assess for possible tubal pregnancy. You would report this service with 76817-52.
Bedside ultrasound documentation should include the anatomical location evaluated, and the reason for the test to show medical necessity. The interpretation and report with findings should be recorded in the patient’s record. The record should include an impression and who performed the test. There is also a requirement of image retention. The image may be placed in the chart or stored in a retrievable location.
Ultrasound has become a useful modality in patient care and gives providers a powerful tool to aid in diagnoses and treatments. Be aware of the many types of ultrasounds and their documentation requirements. As technology advances and these handheld devices are more readily available, more of these services will be provided.
Sarah Todt, RN, CPC, CPMA, CEDC, is the director of Provider Education and Audit at LogixHealth, an ED-specialized provider of coding, billing, and end-to-end revenue cycle services for hospitals, office-based practices, and EDs nationwide. Ms. Todt specializes in emergency medicine and critical care. She has served on the AAPC National Advisory Board (NAB) and the ED specialty exam steering committee, and she presents on ED reimbursement topics.
August 1st, 2012
If you’re not getting paid for unrelated evaluation and management (E/M) services furnished by the same physician during the postoperative period, you may want to brush up on the guidelines for modifier 24 Unrelated evaluation and management (E/M) service by the same physician during the postoperative period. Medicare administrative contractor (MAC) NHIC, Corp. recently published a new provider education article regarding modifier 24 on its website. A quick review might help you to get those claims paid.
According to the jurisdiction 14 MAC, E/M claims billed with modifier 24 are often denied because the medical record submitted for the E/M service doesn’t support a service unrelated to the original major or minor surgery and/or the signature is illegible. Failing to submit requested supporting documentation (denial reason code N29) is also a common reason for a contractor to deny a claim.
Know this: Jurisdiction 1 MAC, Palmetto GBA, recently posted its top denial reason codes for Medicare Part B claims in June. Denial reason code N29 Documentation requested for this date of service was not received or was incomplete made the top of the list. Providers are encouraged to review the report to prevent similar denials that prevent claims from being processed in a timely manner.
To ensure proper payment of E/M services billed with modifier 24, NHIC, Corp. offers these billing tips:
- Use of modifier 24 is appropriate with CPT® codes 99201-99499 and 92012-92014.
- Services submitted with modifier 24 must be sufficiently documented in the medical record to establish that the visit was unrelated to the condition for which the surgery was performed. Do not submit the documentation unless requested to do so.
- Append modifier 24 to the E/M code performed during a pre- or postoperative period of a procedure performed by the same physician, but which is unrelated to the major or minor surgical procedure performed.
- When submitting modifier 24 with codes (99291-99292), documentation (a diagnosis is acceptable) that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed must be submitted.
Read the provider education article for examples of supporting documentation and signature requirements.
Tip: Also newly published by NHIC, Corp. are education articles on prepayment probe review findings for diagnostic ultrasound of the abdomen (CPT® 76700), and physicians tips for Medicare record authentication.
August 11th, 2011
National Government Services, Inc. (NGS) recently published a supplemental instructions article (SIA) with updated coding and other guidelines for the Abdominal and Pelvic Ultrasound Local Coverage Determination (LCD).
Effective Sept. 1, bill claims submitted to NGS, all services/procedures on the same day for the same beneficiary by the physician/provider on the same claim.
The SIA adds the urgent care facility (20) as one of the places of service the following CPT® codes are payable for the global, technical, and professional components.
76700 Ultrasound, abdominal, real time with image documentation; complete
76705 Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)
76830 Ultrasound, transvaginal
76856 Ultrasound, pelvic (nonobstetric), real time with image documentation; complete
76857 Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles)
Review the LCD and learn of other medical policy Parts A and B updates, revised LCDs, SIAs, and coverage articles effective Sept. 1. on the NGS Medicare University contractor Web site.
September 14th, 2009