Chapter 4: Point-of-Care Ultrasound Coding, Billing, and Reimbursement

INTRODUCTION

Emergency physicians who utilize point-of-care ultrasound (POCUS) should have an understanding of the processes for billing and reimbursement for this service. As the American Medical Association (AMA) supports the use of ultrasound,¹ it also supports reimbursement for ultrasound imaging performed by appropriately trained physicians.² Similarly, the Centers of Medicare and Medicaid Services (CMS) supports billing for POCUS examinations by any physician.³ According to the Medicare Claims Processing Manual, Medicare Administrative Contractors (MAC) must pay for the professional component of radiology services furnished by a physician to an individual patient in all settings under the fee schedule for physician services regardless of the specialty of the physician who performs the service.⁴

DOCUMENTATION REQUIREMENTS

In order for a physician or physician group to charge for an ultrasound examination, the physician must ensure appropriate documentation. Current procedural terminology (CPT)⁵ is the standardized coding system used to code medical services and procedures. CPT codes are five-digit numeric or alphanumeric codes divided into four categories of codes. Category I codes have descriptors that correspond to a service or procedure, such as ultrasound examinations. Both CPT and CMS have guidelines for documenting POCUS examinations. CPT has outlined three items that must be included: a permanently recorded image(s) that must be saved and available for review, but not necessarily has to be part of the written medical record; a final written report; and, if billing for a complete examination and not including all of the components of the examination, there must be a written description as to why they were omitted. Those reasons might include, but are not limited to, body habitus, bowel gas, patient discomfort, etc.

CMS guidelines specify the following five components of documentation: an order,⁶ medical necessity, a written report, interpretation, and physician’s signature. Medical necessity, sometimes written as the indication(s), is the clinically relevant reason for obtaining the ultrasound. All procedures, including ultrasound examinations, have specific ICD-10 diagnosis codes that support the medical necessity of the ultrasound performed. CMS carriers in specific geographic areas publish Local Coverage Determinations (LCDs). The LCDs guide providers on use of particular CPT codes and the appropriate ICD-10 codes to justify each CPT code. If the incorrect ICD-10/CPT pairing is submitted on a claim, the ultrasound examination will most likely be denied. The written report should include the time, date, patient’s name, date of birth (or some other unique identifying information), the images obtained, anatomy reviewed, and pertinent positive and negatives. The interpretation is sometimes called the clinical impression, or commonly referred to by radiologists as the final reading of the ultrasound; it is an encompassing diagnosis given all the findings on the ultrasound or a summary of the pertinent findings of the ultrasound as a whole. Below is a sample of ultrasound documentation including the necessary components: