No starry-eyed future doctor goes to medical school to learn how to document, code, bill, etc. Furthermore, most residency programs fall far short of instructing their residents on how to comply with CMS and commercial insurance regulations. Yet, this is the reality that each practitioner faces daily. In this chapter, I hope to provide guidelines on how to document your ultrasound examination and code appropriately for maximum reimbursement.
This discussion begins with a review of the notion of CPT, or current procedural terminology, coding. Designed and maintained by the American Medical Association as a universal language for identifying and reporting medical, surgical, and diagnostic services, CPT codes enable clear communication for utilization review and claims processing by government and commercial payers. The CPT code describes the service performed, regardless of the performing individual (surgeon, radiologist, gastroenterologist, etc.). Most ultrasound examinations and procedures have CPT descriptors, and can be listed in addition to evaluation and management (E & M) codes.
Many ultrasound examinations performed by interventionalists as an adjunct to a procedure are of the “limited” variety, where a focused examination is performed. For example, a complete ultrasound examination of the abdomen (76700) consists of real-time scans of the liver, gallbladder, common bile duct, pancreas, spleen, both kidneys, upper abdominal aorta, and inferior vena cava. Ultrasound assessment for hepatic lesion ablation, however, would fall under code 76705, “Ultrasound, abdominal, real time with image documentation, limited,” where a limited study refers to a single quadrant, diagnostic problem, or even a follow-up study. The most recent definition for a limited examination by CPT is one in which less than the required elements for a complete examination are performed and documented.
Category III codes are a temporary set of codes for emerging technologies, services, and procedures. They are used predominantly to track the usage of these procedures, and may be in the FDA approval process, or for research purposes. Category III codes are archived after a period of 5 years, unless the original requestor petitions for either retention as a Category III or conversion to a Category I (if Category I criteria are met). These codes are identified as four-digit numeric followed by a T. There are several vascular ultrasound procedure codes that fall under this category.
Certain modifiers may be added to the primary CPT code to clarify or further the information provided by the code alone. The most common modifiers used with ultrasound procedure codes are:
-26 Professional Component
Unmodified ultrasound CPT codes are “global” service codes, where the technical and professional components are combined. Technical component refers to the facility portion, and includes equipment cost and maintenance, technician services, and supplies. Professional component refers to the physician interpretation services accompanied by a separate, distinctly identifiable report. When a physician uses an ultrasound machine in the operating room, for example, the machine is typically owned and maintained by the ...