$traight Talk XXIV December 8, 2015

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Cornelius McDaniel
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1 $traight Talk XXIV December 8, 2015 Sandy Steele, CPC, CPMA, CEDC, CAC 1 Ultrasound and Ultrasound Assisted Procedures Documentation Requirements Indication medical necessity: The record must indicate why the test was medically necessary. Interpretation: A written interpretation and report must be completed. The report would be maintained in the patient s record. The documentation should describe the structures/organs studied and an interpretation of the findings. (a separate sheet is not required) Image Retention: ultrasound examinations require permanently recorded image(s) to be stored in the record and be available for future review. Provider s name: the interpretation must identify the provider performing and interpreting the study. Simply recording the results obtained by the radiologist is not a billable service. 2 Common Emergency Department Ultrasound Codes: FAST Exam would report two codes (procedure is two steps) FAST: Focused Assessment with Sonography for Trauma Common indication: Chest and/or abdominal trauma Chest Echocardiography, limited exam only of cardiac status, mainly to assess for tamponade, or pericardial fluid limited abdominal ultrasound (e.g. single organ, quadrant, follow-up) physician checks for free fluid or blood in the abdomen 3 1

2 Suspicious Abdominal Aortic Aneurysm (AAA) Ultrasound, retroperitoneal (e.g., renal, aorta, nodes) real time with image documentation; limited RUQ pain suspect gallstones?? Ultrasound, abdominal, real time with image documentation; limited (single organ, quadrant, follow-up) *SAME CODE assigned as part of the FAST exam* 4 Hematuria & Flank pain may require this ultrasound study: Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; limited *SAME CODE assigned for the study to R/O AAA* Pelvic US evaluation of pregnancy: US pregnant uterus, real time with image documentation, limited (e.g., fetal heart beat, ectopic, fetal viability, etc.) (CPT represents a focused quick look exam limited to the assessment of one or more of the elements listed in code 76815) US pregnant uterus, real time transvaginal (complete exam, not limited most ER studies will be less than complete consider adding modifier 52 reduced services) 5 Bedside Ultrasound in the Emergency Department MODERATE (CONSCIOUS) SEDATION NOT PREGNANT: US, pelvic (nonobstetric) real time with image documentation; limited (looking for ovarian cysts, fluid, torsion, abscess etc.) Per CPT represents a focused examination limited to the assessment of one or more elements listed in code urinary bladder, prostate and seminal vesicles, any pelvic pathology (e.g., bladder tumor, enlarged prostate, free pelvic fluid, pelvic abscess) When the patient is not pregnant, or the status of the pregnancy is unknown PRIOR to the examination, then the non-obstetric code should be used

3 Other US services that might be provided in the emergency department: measurement of post-voiding residual urine and/or bladder capacity by ultrasound, NON IMAGING (image not required, requires numeric measurement, may be used to evaluate urinary retention) Careful, nursing staff often performs this procedure. SOFT TISSUE MASS (may be used to distinguish abscess from cellulitis) neck upper extremity axilla chest wall pelvic wall perineum lower extremity abdominal wall 7 Ultrasound Guidance Procedures US guidance for vascular access requiring ultrasound evaluation of potential access sites. Realtime ultrasound visualization of vascular needle entry with permanent recording This code is billable when the dynamic technique is performed; the physician uses the US throughout the procedure identifying the vessel as well as direct visualization of the needle entering the vessel. A permanently recorded image is required to be on file. Report the code primary code first then 76937: adult central venous line placement years and older, venipuncture (lab or IV start) 8 Ultrasound Guidance Procedures US guidance for needle placement Requires imaging supervision, interpretation and image retained. May assign US guidance for: Nerve blocks Biopsy Lumbar puncture I & D More specific US guidance for pericardiocentesis, imaging supervision and interpretation 9 3

4 Many CPT codes include US guidance: Ultrasound Guidance Procedures Abdominal paracentesis with imaging guidance Peritoneal lavage, including imaging guidance when performed Thoracentesis, needle or catheter, aspiration of pleural space; with imaging guidance Pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance Image guided fluid collection drainage by catheter NEW 2015 Arthrocentesis of small, intermediate and large joints additional codes to include with ultrasound guidance with permanent recording and reporting 20600, & report without US guidance 20604, & report if US guidance is used 10 Ultrasound Modifiers 26 professional component only, typical for ED physician coding 76 Repeat procedure by the same physician; patient clinically requires a repeat study 77 Repeat procedure by another physician; another physician provides a complete study 59 Distinct procedural service; two or more separate US studies by the ER physician New to CMS (replacing 59) modifier XS A service that is distinct because it was performed on a separate organ/structure 11 Examples of acceptable ultrasound interpretations: Pregnant patient with abdominal pain, bedside ultrasound shows intrauterine pregnancy with good fetal movement, visible heartbeat and auscultated heart sounds at 150 beats per minute. US image permanently recorded Patient with eye pain, transocular ultrasound shows no flap suggestive of retinal detachment. US image permanently recorded Examples of unacceptable ultrasound interpretations: Abdomen ultrasound negative Negative or normal No Abnormality Demonstrated (NAD Coding tip: FAST is an acronym now used by many clinicians to refer to ultrasounds to assess for injury, FAST pregnancy ultrasound is still coded as a pregnancy ultrasound (76815) if appropriately documented. 12 4

5 Reimbursement Reality Medicare Michigan (other than 4 county Detroit Area) $ $ $ $ $ $ Reimbursement Reality CPT it is generally allowable under CPT for two different physicians to report a limited and a complete exam of the same body area. (different sessions) Some payers may only reimburse for the complete study when both are submitted for the same date of service. Watch LCDs and NCDs for reimbursable ICD-10 codes. 14 Reimbursement Reality If your emergency physician group performs US testing but does not separately bill for the procedures: Capture MDM points for the E/M Direct visualization of the study can add points in the amount and complexity of data reviewed section which is counted towards the overall MDM score. 15 5

6 Thank you 16 6

Ultrasound Billing CPT Codes Summary and Notes

Ultrasound Billing CPT Codes Summary and Notes CPT codes for ultrasound examinations are considered to be complete studies unless specified as limited studies in their code definitions. A limited study