Documentation Tips

Documentation Tips: Diagnostic Ultrasound

Documentation Tip: Diagnostic Ultrasound

The keys to payment:

  • Medical necessity
  • Performing the entire service as described in CPT
  • Complete documentation equivalent to a specialist
  • Retained images

US codes require “permanently recorded images” and “a final written report.” “Use of ultrasound without thorough evaluation of organ(s) or anatomic region, image documentation and final, written report, is not separately reportable.” (CPT)

FAST exams are not separately billable if you document them only as quick looks. If all you do is check for fluid around the heart and the abdomen these quick looks cannot be billed as ultrasound studies. You must document at least 2 findings in the heart and 3 in the abdomen.

Acceptable documentation might read “Fast Ultrasound showed good cardiac activity and no pericardial fluid. The abdomen noted that Morison’s pouch has no free fluid, the bladder is full with no surrounding fluid, and splenorenal recess has no free fluid”.

Here’s what one Medicare carrier says:

“Studies that do not meet all of these criteria, no matter what equipment is used, should not be billed under diagnostic ultrasound codes (93303-93305, 93875-93990 or 76506-76999) or any other CPT codes. As an example, an emergency room “quick look” ultrasound to assess the chest for the presence of fluid, blood, pus or a foreign body may be quite useful as an extension of the physical exam. However, it does not meet the above standards and should not be coded as 76604, US Exam, chest, b-scan. Similarly, an echocardiogram performed for the purpose of “not missing a murmur” or to evaluate clinically insignificant murmurs or other cardiac conditions should not be coded with codes 93303-93308 or 93320-93325. Medicare considers these studies to be part of the complexity of the physical examination and not separately reimbursable.” — Trailblazer Medicare

Common Diagnostic Ultrasounds Performed by the ED Provider:

  • 76705-26: Ultrasound of abdomen, limited
  • 76775-26: Ultrasound, retroperitoneal (aorta, nodes), limited
  • 76815-26: Ultrasound, pelvis in pregnant patient; limited
  • 76857-26: Ultrasound, pelvis in non-pregnant patient, limited
  • 93308-26: Echocardiogram, limited
  • 76512-26: Ultrasound, eye, diagnostic, B-scan
  • 51798: Bladder scan/Post-void residual scan measurement (This study does not require the retention of an image)
  • 76536-26: Ultrasound, soft tissue neck
  • 76604-26: Ultrasound, chest/thorax
  • 76882-26: Ultrasound, extremity (soft tissue)

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