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Understanding the intricacies of sonogram billing

Radiology Administrator's Compliance and Reimbursement Insider, October 1, 2006

Ultrasound documentation requirements

Q: Where can we find ultrasound (US) documentation requirements in writing?

A: At the beginning of the diagnostic US section in Current Procedural Terminology (CPT).

“That’s the official coding advice to follow,” says Stacie L. Buck, RHIA, CCS-P, LHRM, RCC, vice president of Southeast Radiology Management in Stuart, FL.

Bundling transabdominal with transvaginal scans

Q: Our US department routinely performs both transabdominal and transvaginal (endovaginal) exams together as part of protocol. Sometimes, the radiologist dictates transvaginal; other times he or she does not.

If the report does not indicate that a transvaginal US was performed, I always question the US department about whether if it was. When I do, they explain, “It is not required due to protocol.” Is it correct to be charging this way?

A: The radiologist must document the performance of the transvaginal examination, as well as the reason for the exam, says Stacy Gregory, RCC, CPC, president of Gregory Medical Consulting Services in Tacoma, WA.

It is common to perform both of these examinations in the same setting for a variety of reasons, but there must be clear and documented medical necessity for both studies, she says.

For example, if during a preliminary transabdominal pelvic ultrasound, some components cannot be visualized (due to obstruction by bowel loops, gas, empty bladder, body habitus, etc.), the technologist may discuss the need for additional imaging with the radiologist.

The radiologist can then request a transvaginal examination to completely evaluate the pelvic contents.

This should not be routine practice or protocol. The transvaginal exam should only be performed on a medically necessary basis, Gregory says.

Have a physician order form on file designed to allow for both examinations (e.g., pelvic ultrasound [with transvaginal ultrasound if needed]).

Duplex evaluations

Q: What CPT code(s) should be assigned for Duplex scans? We normally charge 76870 and 93976. Is this correct?

A: A quick-look use of color flow Doppler simply to verify whether an anatomic structure is vascular should not be separately coded, says Gregory.

In order to separately code for Duplex scanning, evaluation of blood flow—both arterial inflow and venous outflow—must be performed in addition to a gray scale evaluation.

Documentation of an order from a physician for both examinations should be maintained, and medical necessity must be present, she says.

In the hospital setting, the ordering physician may be the radiologist.

An order from the referring physician is required in the freestanding (i.e., nonhospital) and independent diagnostic testing facility settings, says Gregory.

Use of ‘limited’ with Duplex

Q: Can we use the “limited” vascular CPT code 93976 with a prostate ultrasound if we use color the same way it was used during the scrotum exam?

A: No, says Gregory. See requirements for reporting Duplex evaluations in addition to real-time ultrasound examinations.

Documentation and coding for male pelvic scans

Q: Should we always bill for a male pelvis scan when viewing the bladder during an ultrasound? That is our current procedure because our doctors want the prostate measured.

A: In order to code a “complete” male pelvic ultrasound (76856), the report must contain documentation of performance—or attempted performance—of measurement and evaluation of the urinary bladder, prostate, and seminal vesicles, and as well as pelvic pathology.

If less than the above components are evaluated, then the exam should be coded as a “limited” study (76857).

If only the urinary bladder is evaluated, 76857 would also apply.

Q: Can a 76856 (male pelvis), 76770 (retroperitoneum), and 51798 pulmonary vascular resistance be coded at the same time when imaging renals, inferior vena cava, aorta, bladder, prostate, seminal vesicles, and also post void bladder?

A: In this case, 76856 and the 76770 can be billed together if both are ordered and performed, Buck says. n

Insider sources:

Stacie L. Buck, RHIA, CCS-P, LHRM, RCC, vice president, SoutheastRadiology Management, 512 SW St. Lucie Crescent, Stuart, FL 34994, 772/600-0324;stacie@southeastrad.com; www.seradmgt.com.

Stacy Gregory, RCC, CPC, president, Gregory Medical Consulting Services, 2661 N. Pearl St. #364, Tacoma, WA 98407, 253/566-2494; stacy@gregorymedicalconsulting.com.

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