Sunday, August 2, 2009

"FAST" exams & Ultrasound documentation criteria

"FAST" Exams, Ultrasound (US) in the ER/ED, Documentation Criteria for Ultrasound

Q: Do you know anything about FAST Exams, (Focused Abdominal SONOGRAPHY for Trauma ultrasound), 76705? I am trying to find out what documentation I have to have in order to bill them on the profee side, ie, reports, pictures, etc

A: There is no specific CPT-defined code for the usual clinical FAST exam. Rather, the exam is reportable as two distinct limited ultrasound examinations, when the requirements of both are performed:

  • One component of the exam is the limited transthoracic echocardiogram (93308).
  • The other component of the exam is the limited abdominal ultrasound (76705).

Q: What is the difference between a ‘limited’ ultrasound exam and a ‘complete’ ultrasound exam?

A: A complete ultrasound exam is one that attempts to visualize and diagnostically evaluate all of the major structures within the anatomic region. For example, a complete abdominal ultrasound (76700) would consist of real time scans of the: liver, gall bladder, common bile duct, pancreas, spleen, kidneys, upper abdominal aorta and inferior vena cava.

Many emergency department ultrasounds are more focused than “complete.”

As defined by CPT, a limited ultrasound exam is one in which less than the required elements for a complete exam are performed and documented. Given the nature of of the focused ED ultrasound examinations, the limited codes are typically the most accurate for utilization in the ED setting. For example, an abdominal ultrasound used to evaluate the presence of an abdominal aortic aneurysm would be reported as a “limited retroperitoneal ultrasound” (76775).

The one common exception to the rule is the transvaginal ultrasound in the pregnant (76817) and non-pregnant (76830) patient, where there is no corresponding limited procedure CPT.

Q: What CPT modifiers are commonly used in coding emergency department ultrasound examinations?

A: The most common modifier used with ultrasound is probably the -26 Professional Component modifier.

Ultrasound codes are combined, or “global,” service codes that include both the technical component and the professional component. In the emergency department setting, the hospital will typically report the technical component that covers the cost of equipment, supplies, and personnel necessary for performing the service. The professional component is reported by the physician for the interpretation of the ultrasound and documentation of the results.

There is nothing in CPT that prohibits the practitioner from also reporting the technical component (TC), if he/she provides all of the necessary elements. However, some payers with which the practitioner participates might have policies prohibiting payment of the TC to practitioners. For example, Medicare will not pay the technical component to hospital-based (but non-hospital-employed practitioners), even if the practitioners own the equipment, provide the supplies, and their personnel perform the technical service.

Also, modifiers -76 and -77 (repeat procedure or service) possibly used in the setting of repeat scans as patients deteriorate (eg, AAA), or planned serial exams (eg FAST).

Some emergency physician practices have contemplated purchasing their own ultrasound machines and billing for the global (professional plus technical) service. Physicians considering this option are well advised to seek legal counsel given the compliance complexities of these kinds of business relationships.

Q: What documentation is necessary for the coding of emergency department ultrasound examinations?

A: For each ultrasound service performed/coded, the following is necessary:

  • Interpretation – a written interpretation and report must be completed and be maintained in the patient’s medical record. The report must describe the structures or organs studied and supply an interpretation of the findings.
  • Medical necessity – the medical record documentation must indicate why the test was medically necessary.
  • Image Retention – appropriate image(s) of the relevant anatomy / pathology must be permanently stored and available for future review. Please note that an image is now required for all procedures performed with an ultrasound.

Additional Recommendations:

  • The report should identify who performed the procedure and who interpreted the procedure.
  • The scope of the study should be described including whether the study was complete or limited, a repeat examination by the same physician, a repeat examination by a second physician, and/or a reduced level of service.

Q: Does the patient’s pregnancy status matter when coding for a transabdominal or transvaginal ultrasound?

A: The pregnancy status of the patient and the purpose of the ultrasound examination determine the proper code.

  • Transabdominal ultrasound:
  • When the patient is known to be pregnant and the physician is utilizing ultrasound to evaluate the pregnancy or a suspected complication of, or to the pregnancy, then the obstetric pelvic codes should be used (76815).
  • When the patient is not pregnant, or the status of the pregnancy is unknown prior to the examination, and the ultrasound is used to evaluate pelvic pain, amenorrhea, vaginal bleeding or non-gynecologic pelvic pathology, then the non-obstetric codes should be used (76857).
  • Transvaginal ultrasound
  • Prior to 2004 there was a single code for transvaginal ultrasound that did not differentiate between pregnant and non-pregnant patients. Now, there are two codes depending on the pregnancy status.
  • If the patient is pregnant use the code (76817).
  • If the patient is NOT pregnant use the code (76830).
  • It is important to note that there is only a complete exam code for transvaginal ultrasound. Many emergency department transvaginal ultrasounds are less than complete exams, thus it is appropriate to use the modifier -52 Reduced Services.

Example: pregnant transvaginal ultrasound, professional service only (76817-26, -52)

Q: We use ultrasound frequently for placing central lines. What are the requirements for billing for the ultrasound?

A: In 2004 CPT designated a new code specifically for central venous access with ultrasound guidance (76937). The current CPT description is:

“Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-timeultrasound visualization of vascular needle entry, with permanent recording and reporting.“

There are several unique aspects of the central venous and peripheral vascular access with ultrasound guidance code of which users must be aware. The first is that the code is intended for use only when the ultrasound is used with the “dynamic” technique, as opposed to the “static” technique which is not considered a reimbursable service.

The static technique utilizes the ultrasound to identify the vessel, but is not used during line placement. In the dynamic technique the physician uses the ultrasound throughout the procedure from initial identification of the vessel through direct visualization of the needle entering the vessel. A recorded image of the procedure is required for coding.

When coding a central line placement under direct dynamic visualization with ultrasound it is appropriate to code 76937 for vascular ultrasound guidance and 36556 for the adult central venous line placement.

Q: If we use the ultrasound to aid in a procedure, do I code for both the ultrasound and the procedure?

A:. It is appropriate to code for both the ultrasound guidance and the procedure performed. For example when performing an I+D of an abscess with ultrasound assistance, both the I+D 10060 and the ultrasound guidance for needle placement 76942-could/should be coded

Q: Do we need to store an ultrasound image to be able to code for the exam?

A: In the past, the requirement for image retention was a point of discussion. That has changed. As of 2005, CPT now clearly states that image retention is mandatory for all diagnostic and procedure guidance ultrasounds.

CPT does not specify how the images are to be stored or how many images are required. Appropriate image(s) demonstrating relevant anatomy/pathology for each procedure coded should be retained and available for review

Q: Can an emergency physician code for a limited examination if the patient also gets a complete examination performed by another medical specialist on the same date?

A: It is allowed under CPT for two different physicians (e.g., two different medical specialists) to report a limited and a complete exam of the same anatomic description at different exam sessions, on the same date of service, if the medical record supports the medical necessity of the two separate procedures. For example, on some occasions an initial limited examination by an emergency physician will be inconclusive or demonstrate an unexpected finding requiring a complete examination, or a follow-up examination by another medical specialist. It is required that each examination, limited or complete, stand on its own merit as a medically necessary study. It is important to document in the medical record why the repeat study was required.

However, it is inappropriate for the same physician to code for a limited exam followed by a complete exam of the same anatomic region in the same exam session. In this case , the limited exam is viewed as being included in the more comprehensive complete service. Ie “bundled”

When coding for a limited and complete exam by two different practitioners, the use of the -77 modifier “Repeat Procedure by another physician” This may justify payment for both studies, but you may still get a denial, and have to appeal.

Some payers might recognize only the more complete examination and therefore pay for the complete study only, denying payment for the limited evaluation procedure done by the emergency physician.

*** Thank you extended to the ACEP website for this information ***

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