Correct Coding for the Usage of Ultrasound in Office Settings:

Correct Coding for the Usage of Ultrasound in Office Settings:

7/18/2015

In the physician office setting, coders are very familiar with the concept of coding for chest x-ray and x-ray procedures.  However, many more providers are utilizing ancillary services within their office practice to boost revenue, and to make diagnostic testing more convenient for their patients.  The usage of ultrasound at the bedside, or within the office practice is becoming more and more common within provider specialty based clinic settings.  Most people equate getting an ultrasound primarily in an OB/GYN practice, as it is used frequently for early fetal viewing and for diagnosing female gynecologic issues. However, ultrasound is used in specialty areas such as Ophthalmology, ENT practices, General Surgery, Orthopedic, Urologic and many more provider specialty clinics. 

Ultrasound is defined as sound waves with frequencies which are higher than those audible by people. Ultrasound images are made by sending pulses of ultrasound waves into tissue using a probe. The sound echoes off the tissue or areas being scanned and are then recorded and displayed as an image.

Ultrasound (also known as sonography) can be extremely useful in many specialty practices.  CPT has given coders a broad range of codes to choose from.  In the CPT book set-up the diagnostic ultrasound section is set up similar to that of the traditional x-ray codes.  Ultrasound is set up by body areas

·         Head and Neck

·         Chest

·         Abdomen and Retroperitoneum

·         Spinal Canal

·         Pelvis

o   Obstetrical

o   Non-Obstetrical

·         Genitalia

·         Extremities

CPT then gives us codes for

·         Ultrasonic Guidance Procedures

·         Other Procedures

There are some additional definitions that CPT has included in the guidelines of coding ultrasound.  These definitions are

·         A-Mode: The A mode is the simplest form of ultrasound imaging and is not frequently used. The ultrasound wave that comes out of the ultrasound probe travel in a narrow straight path.

·         M-Mode: or (measurement mode) is a one-dimensional measurement procedure with movement of the scan to record the amplitude and velocity of moving echo-producing structures

·         B-Scan: Is a two-dimensional scanning procedure that has a two-dimensional display or image.  The B scan is the most common mode of ultrasound and is used often in anesthesia. The complete description of the mode is “real time, 2 dimensional (2 D), B scan”. The 2 dimensional (2D) refers to the fact that the image has two dimensions; horizontal (X axis) and vertical ( Y axis).

·         Real-time Scan: is a two-dimensional (2-D) scan with a display of both two-dimensional structure and motion with time.

·         Doppler mode: This mode makes use of the Doppler effect  in measuring and visualizing blood flow. 

o   Duplex: a common name for the simultaneous presentation of 2D and pulsed wave doppler information. (Using modern ultrasound machines, color Doppler is almost always also used

·         3-D Fetal Scanning: In 3D fetal scanning, the ultrasound waves are sent straight down and reflected back, then are sent at different angles. The returning echoes are processed by a sophisticated computer program resulting in a reconstructed three-dimensional volume image of the fetus's surface or internal organs.  ( similar to CT scan images)

Physicians and providers who have begun utilizing ultrasound in their office practices are finding that having ultrasound readily available enhances the ability to diagnose and treat issues and problems much more quickly than having to send patients out to a traditional hospital setting or practice to have these diagnostic scans performed.  In addition, they have found that in the case of post-surgical patients, having this ancillary resource readily available makes follow up care more complete and can negate more extensive follow up services. 

In addition to CPT, the AIUM (American Institute of Ultrasound in Medicine) also has practice guidelines available on-line to help guide the practice of diagnostic ultrasound. AIUM and CPT require that all ultrasound examination have a permanently recorded image with measurements and a final written report.  If the scan is performed as a global scan, then no modifier are needed.  If the technical component is performed, and no formal interpretation is completed, then the modifier TC should be appended to the CPT code when billing.  The AIUM has a website dedicated to all the practice guidelines for ultrasound and can be found at http://www.aium.org/resources/guidelines.aspx .

CPT also includes definitions that are used within ultrasound services.  The terms “complete”, “limited”, and “follow-up” are noted throughout the ultrasound service codes.   As a coder, it is your job to understand what these definitions mean in relation to the scan being performed.   CPT guidelines state that if a code states performance of a “complete” scan, then all areas represented within that code will have been scanned and reported back on.  If a “complete” scan has not been performed, then a coder needs to report the scan as “limited”.

If you review the CPT code 76700 Ultrasound, abdominal, real time with image documentation; complete, the guidelines state that for this to be “complete”  there needs to be real time scans of the liver, gall bladder, common bile duct, pancreas, spleen, kidney, the upper abdominal aorta and inferior vena cava including any abdominal abnormalities.   If not all of this was performed, it is then appropriate to use code 76705 Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant, follow-up).   It is inappropriate to append a -52 “reduced services” modifier to radiology ultrasound codes, when a CPT code is available that represents the true work performed.

In coding of ultrasound services, just like in coding of other radiologic services, the term “separate procedure” is still considered to be an “unrelated” or “distinct” service from other ultrasounds performed at that same time.  The usage of modifier 51 is inappropriate to be appended to radiologic and ultrasound services.   However the usage of modifier 59 will indicate that the subsequent ultrasound procedures are “separately identifiable” and should be documented and billed as such.

As a coder, always find out if you are coding for an ultrasound procedure, and if the equipment that the ultrasound is performed with is, or is not owned by the provider/physician practice.   This information is integral to correct billing of the ultrasound services.

·         If the equipment is owned by someone other than the physician/provider clinic, the modifier -26 professional Component only, should be appended to the CPT code for billing. 

·         If the equipment is owned by the provider/physician practice but no written report has been provided, modifier –TC (Technical component only) should be billed and appended. 

·         If the equipment is owned by the provider/physician practice and all components were performed then a global code should be submitted for billing. 

Another coding/billing issue to be aware of is the billing claim should note the POS code to be “11”  – Office.   (definition: location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis)

Insurance payers such as Blue Cross, Medicaid, Tri-Care and Medicare expect to see the modifier 59 appended when multiple scans are performed and billed.  Most payers will deny your ultrasound claims if a modifier 51 or 52 is appended to a claim. 

Not only is ultrasound being utilized by itself in office based diagnostic applications, but it is also used for diagnostic/therapeutic applications too.  In the section of the CPT book for Ultrasonic Guidance Procedures,  code 76942 Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation; can and should be coded when used in coordination with a FNA (Fine needle aspiration) or localization.  Code 76942 can be used in addition to the FNA code 60100 Biopsy Thyroid, percutaneous core needle.  

In Obstetric, Gynecology and Reproductive medicine, providers are utilizing ultrasound guidance for retrieval of oocytes/eggs from the ovary for usage with InVitro Fertilization with code 76948.  Maternal Fetal Medicine also uses ultrasound guidance for in-office procedures such as code 76945 for chorionic villus sampling and code 76946 with amniocentesis.

Urology has also begun using ultrasound more and more within the office.  CPT code 76705 Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant, follow-up) is coded when the urologist is looking specifically for kidney stones, bladder, or ureteral or urethral pain.    In addition, Ultrasound is used commonly within the urology office to view scrotal and prostate issues.

Operative/Coding Examples

Urology (Established patient)

John Doe presented to my office this am complaining of swelling in the left testicle and some right sided testicular pain for the last week.  Has been taking Tylenol for the pain with minimal relief.   Visual exam and palpation of scrotum is benign, however, will evaluate with in-office bilateral scrotal ultrasound.  After review of the u/sound – diagnosis of bilateral hydrocele and left epididymitis.  Patient wants to take a “wait and see” approach.  Patient will continue using Tylenol for pain and warm soak/compresses.   Will consider other medical or surgical intervention if no improvement.   Will see patient back in 30 days.

Scrotal Ultrasound Findings:

Description: Left testicular swelling for one day. Scrotal Ultrasound. Hypervascularity of the left epididymis compatible with left epididymitis. Bilateral hydroceles.
FINDINGS: 

The right scrotum/testicle is normal in size and attenuation, it measures 3.2 x 1.7 x 2.3 cm. The right epididymis measures up to 9 mm. There is a hydrocele on the right side. Normal flow is seen within the testicle and epididymis on the right.

The left testicle is enlarged, but still within the normal limits in size and attenuation, it measures 3.9 x 2.1 x 2.6 cm. The left testicle shows normal blood flow. The left epididymis measures up to 9 mm and shows a markedly increased vascular flow. There is mild scrotal wall thickening. A hydrocele is seen on the left side.

IMPRESSION:
1. Hypervascularity of the left epididymis compatible with left epididymitis.
2. Bilateral hydroceles. 

Coding Consideration:  Office Visit 99213.25 +  U/sound 76870

Gynecology (Established patient)

Pt is a25-year-old G0, LMP November 25, 20XX. She comes in today in because of irregular periods and pelvic pain.  She is complaining of a three-month history of lower abdominal pain for which she has been to the ED twice. She describes the pain as bilateral, intermittent, and non-radiating. It decreases slightly when she eats and increases with activity. She states the pain last for half-a-day. It is not associated with movement, but occasionally the pain is so bad it has induced vomiting. She has tried LactAid, which initially helped, but then the pain returned. She has tried changing her diet and Pepcid AC. She denies constipation and diarrhea. She has had some hot flashes, but has not taken her temperature. In addition, she states that her periods have been very irregular coming between four and six weeks. They are associated with cramping, pain and heavy bleeding which she is not happy about.

PE: VITALS: Height: 5 feet 5 inches. Weight: 125 lb. Blood Pressure: 120/88. GENERAL: She is well-developed, well-nourished with normal habitus and no deformities. ABDOMEN: Soft, nontender, and nondistended. There is no organomegaly or lymphadenopathy. PELVIC: Deferred.

A/P: Abdominal pain, unclear etiology.  Performed Trans-vag ultrasound and right ovary appears normal.  Left ovary is enlarged, with cystic type mass.  However, given that she has irregular periods that are painful for her, I have recommend either short interval followup versus laparoscopic evaluation given the large size and complex nature of the left ovary. She will followup  in 30 days for pain, bleeding  and review of enlarged ovary to see if resolved.  Patient given script for norco x 10 pills for extreme pain.   Will see patient back in 30 days for follow-up and repeat u/sound.

Ultrasound - Transvaginal

Description: Transvaginal ultrasound to evaluate pelvic pain.
EXAM: Transvaginal ultrasound.
HISTORY: Pelvic pain.

FINDINGS: The right ovary measures 1.6 x 3.4 x 2.0 cm. There are several simple-appearing probable follicular cysts. There is no abnormal flow to suggest torsion on the right. Left ovary is enlarged, demonstrating a 6.0 x 3.5 x 3.7 cm cystic mass that could represent a large hemorrhagic cyst versus abscess. There is no evidence for left ovarian torsion. There is a small amount of fluid in the cul-de-sac likely physiologic.

IMPRESSION:
1. No evidence for torsion.
2. Large, complex cystic left ovarian mass as described. This could represent a large hemorrhagic cyst; however, an abscess cannot be excluded.

Coding Consideration:  Office Visit 99213.25 +  U/sound 76830

Thyroid U/sound in office

Indication: Patient with newly diagnosed hyperthyroidism

Technique: A sonogram of the thyroid gland was performed assessing gray-scale appearance and color doppler flow and real time imaging

Comparison: Initial scan

Findings:
The left lobe is slightly enlarged in size measuring [5.1] x [1.6] x [1.5] cm. The right lobe is slightly enlarged in size measuring [5.2] x [1.4] x [1.6] cm.
No nodules are seen. The isthmus is normal in size measuring [1.25] in maximum AP diameter. No adjacent enlarged lymph nodes are seen.

Impression: With the slightly enlarged status of the rt and lt lobe, will send patient for enhanced CT with contrast  for more comprehensive views. 

CPT Code: 76536

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.