SPOCUS

Reimbursement Statement

SPOCUS Reimbursement Statement

Download PDF Reimbursement Statement

Clinical ultrasound is a separate entity, that is distinct from the physical examination and adds anatomic, functional, and physiologic information to the care of the acutely-ill patient.1 The use of clinical ultrasound is sufficiently developed that it can be considered essential to good patient care in diagnosing, monitoring and treating a wide variety of conditions, and should be billed as a separate billable procedure.2

Although billing for diagnostic and procedural ultrasound is rather straightforward, SPOCUS frequently encounters questions regarding advanced practice provider (APP) billing. Diagnostic and procedural ultrasound performed by PA/NPs should be coded and reimbursed in the same manner as any other procedure which is performed in the course of the patient's care, using Current Procedure Terminology (CPT) codes. The CPT code and the modifier that most accurately describes the ultrasound exam/procedure performed should be included in the documentation. It is essential to verify each payer's specific payment and coverage policy through the payer or the local CMS representative.

Nearly all payers, including Medicare and Medicaid, cover medical and surgical services provided by APPs, in accordance with state law. The services are submitted/billed under the name of the APP or under the name of the physician depending on payer policy.

Medicare pays the PA's employer for medical and surgical services provided by PAs in all settings at 85 percent of the physician fee schedule. These settings include hospitals (inpatient, outpatient, operating room and emergency departments), nursing facilities, offices, clinics, the patient's home and for first assisting at surgery. In certain circumstances, evaluation and management services provided by PAs may be billed under the physician's name and provider number by meeting Medicare's "incident to" or shared visit billing guidelines. Medicare authorizes PAs to personally provide all diagnostic services and requires that those services be billed under the PA.

Commercial insurers do not necessarily follow Medicare policies regarding reimbursement amounts and coverage rules, but are similar to Medicare in that services are billed either under the PA's name or the collaborating physician's name. Always obtain local payer requirements to ensure proper billing.

Generally, APPs are covered when performing diagnostic ultrasound or using ultrasound guidance during the performance of a procedure, as authorized by state law. Depending on the particular imaging requirement, the location of the service and other factors, there may be a distinction between the technical component (TC) and professional component (PC) of ultrasound utilization. When appropriate, APPs may report a global service (PC and TC combined) or either the PC or TC, based on the service(s) delivered.

APPs, like physicians, must meet applicable payer guidelines for medical necessity, coverage policy and documentation requirements to obtain reimbursement for their services. In addition, PAs and physicians use the same ICD codes and CPT codes and modifiers to report and describe the services they render.

SPOCUS supports The American College of Emergency Medicine's policy on certification by external entities and believes that an external certification process would impede the use of this critical clinical skill and adversely affect patient care. Further, any external certification process should not be utilized as a requirement for hospital privileges or credentialing, nor for reimbursement by ACOs, MCOs, CMS or other third-party payers.3

Reimbursement Resources

SPOCUS recognizes that a well run clinical ultrasound program depends on fair reimbursement to be economically viable. SonoSite has created an excellent site to educate providers with coding and reimbursement information, and you don't have to own a SonoSite machine to take advantage of the learning.

SonoSite Reimbursement Guides

  • Anesthesiology – Ultrasound Reimbursement Information
  • ASC – Ultrasound Guidance of Regional Anesthesia – Ultrasound Reimbursement Information
  • Echocardiography – Ultrasound Reimbursement Information
  • Emergency Medicine – Ultrasound Reimbursement Information
  • Endocrinology – Ultrasound Reimbursement Information
  • Intensive Care Unit – Ultrasound Reimbursement Information
  • Musculoskeletal – Ultrasound Reimbursement Information
  • Obstetrics and Gynecology – Ultrasound Reimbursement Information
  • Pain Management – Ultrasound Reimbursement Information
  • Pulmonary – Ultrasound Reimbursement Information
  • Surgery – Ultrasound Reimbursement Information
  • TEE – Ultrasound Reimbursement Information
  • Vascular Access – Ultrasound Reimbursement Information

CPT

Current Procedural Terminology (CPT) codes are a uniform coding system that facilitates the reporting of procedures. The CPT coding system has descriptive terms that help with identifying the codes for the reporting of medical, surgical, and diagnostic services. This system provides a communication tool for medical care and utilization review as well as a claim-processing tool utilized by both governmental and private payers.

CPT codes describe procedures that have been performed. CPT codes are the same for every provider, regardless of specialty, clinical field or practice setting.2

Complete versus Limited Ultrasound Exams

Within the CPT codes for ultrasound procedures, there is often a distinction between complete and limited studies. A complete study, as defined by the CPT, is one in which an attempt is made to visualize and diagnostically evaluate all of the major structures within the anatomic description.

If less than the required elements for a "complete" exam are reported, the "limited" code for that anatomic region should be used. If a limited examination is performed and a clinical finding is encountered which necessitates a complete exam then the complete study may be performed and billed.

Ultrasound used in a "focused" way most often will be appropriately coded as a limited study, as its mission was to answer a specific clinical question in a particular region or area of the body.

Example (FAST exam): A FAST examination will be coded by anatomic location. The question of whether a patient is in shock from free fluid, pericardial effusion or pneumothorax requires three distinct codes: 1) cardiac 93308, 2) abdomen 76705, and 3) chest 76604.2,7

Diagnostic Ultrasound versus Ultrasound Guidance Procedures

Diagnostic ultrasound procedures investigate a source of disease or exclude pathology by answering a narrow clinical question. Conversely, ultrasound guidance procedures are used to guide an invasive procedure, for example needle placement.

Per the National Correct Coding Initiative, diagnostic ultrasound and procedural ultrasound codes can be reported separately if each service is distinct and separate. If a diagnostic ultrasound study identifies a previously unknown abnormality that requires a therapeutic procedure with ultrasound guidance at the same patient encounter, both codes may be reported separately.4

Modifiers

Modifiers are additional numbers added to the CPT code which help further describe the procedure being performed without changing the definition of the code. More than one modifier can be used per CPT code.

-26 Professional Component

Reported by the provider for interpreting the examination and preparing a separate complete written report.

-52 Reduced Services

Under certain circumstances a service is partially reduced or eliminated at the provider's discretion. The usual CPT code is used with the added -52 modifier indicating that the typical procedure was not performed as described, but rather at some reduced level of service.

-59 Distinct Procedural Service

Used to report procedures that are distinct but have the same CPT code. For example, if a patient had multiple foreign bodies in both extremities, the 76881 or 76882 code would be used twice with a -59 modifier.

-76 Repeat Procedure by Same Provider

Defines a repeat procedure by the "same physician or provider" on the same date of service or patient session. Providers in the same specialty, same group and during the same encounter are viewed from a billing perspective as the "same physician".

TC – Technical Component

Represents the cost of the equipment, supplies and personnel to perform the procedure. Identified by appending modifier TC to the procedure code.

Global Service

Includes both professional and technical components. Identified by reporting the eligible code without modifier 26 or TC.

CMS and private insurers make a distinction between services provided at a private office and those provided at the hospital. The same patient visiting the emergency room with the same ultrasound should receive the code 76705-26, as the hospital will then bill for the facility fees.

Selecting the Correct CPT Code

Under the Medicare program, the physician should select the diagnosis or ICD-10 code based upon the test results. If the test does not yield a diagnosis or was normal, use the pre-service signs, symptoms and conditions that prompted the study. If the test is a screening examination ordered in the absence of any signs or symptoms, select "screening" as the primary reason for the service.7

Documentation Requirements

Medical Necessity

Ultrasounds must have documented medical necessity or study indications, and meet the requirements of completeness for the specific CPT code that is billed. Each component of a FAST exam cannot be properly coded unless there is a medical indication such as documented chest pain, bruising, hypotension, or dyspnea.

Written Interpretation

The findings should be immediately communicated to other providers and consultants by a separate written report maintained in the patient's medical record.

The report should include:

  1. Date and time of examination
  2. Name and hospital identification number of the patient
  3. Patient age, date of birth, and sex
  4. Name of the person who performed and/or interpreted the study, and clinical findings
  5. Indication for the study, the scope (complete vs limited), and whether this is a repeat study
  6. Impression and differential diagnosis, as well as the need for follow-on exams and incidental findings
  7. Mode of archiving the data (where images can be found)

Image Capture

All diagnostic ultrasound examinations should have the orienting anatomy labeled and must have permanently recorded images maintained in the patient record. The stored images do not need to be submitted with the claim, however documentation must be available to the insurer upon request. The CPT does not require a certain number of images, but does require that the images captured reflect the reported finding(s).5

Conclusion

Clinicians, to include APPs, performing clinical ultrasound should code and bill for ultrasound exams as they would for any other billable procedure performed during the patient's encounter. This document is intended to provide general information and knowledge of the billing process which will ensure the financial well-being of all clinicians employing clinical ultrasound. Individual questions should be referred to the payor or to the local CMS representative.

References

  1. 1.Geria RN, Raio CC, Tayal V. Point-of-care ultrasound: not a stethoscope-a separate clinical entity. J Ultrasound Med 2015;34:172-3.
  2. 2."ACEP Coding and Reimbursement Document 2009." Emergency Ultrasound Section, American College of Emergency Physicians. Resnick, Hoffenberg, Tayal, Dickman
  3. 3.Emergency Ultrasound Certification by External Entities. ACEP, Clinical Practice and Management Policy Statement.
  4. 4.National Correct Coding Initiative. Radiology Section, IX-21, revised 1/1/2016. https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd
  5. 5.ACR Practice Parameter for Communication of Diagnostic Imaging Findings. American College of Radiology.
  6. 6."ACEP Clinical and Practice Management Questions." American College of Emergency Physicians. McKenzie C.
  7. 7.Ness, E. How to Set Up an Ultrasound Presence in Your ED. ACEP Clinical Practice and Management.
  8. 8."ICD-10-CM Official Guidelines for Coding and Reporting FY 2016." http://www.cdc.gov/nchs/data/icd/10cmguidelines_2016_Final.pdf
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