Medicare patients treated in outpatient hospital departments such as the Emergency Departments and observation units, as well as ambulatory surgery centers, are considered outpatients. Billing for these outpatient Medicare patients follows the Outpatient Prospective Payment System (OPPS). While the professional fees are unaffected by inpatient and outpatient status, the facility fees are affected. Facilities list the same CPT code the physician is billing for professional services, and the CPT code is matched to the appropriate ambulatory payment classication (APC) code. While most diagnostic radiology codes are reimbursed separately under their associated APCs, the TC of image-guidance procedures are bundled into packaged services for the actual procedure performed. For example, a clinician performs an ultrasound-guided peripheral IV on a challenging patient in the ED.The physician bills the professional fee for the venous access and add-on ultrasound-guided vas­cular access code. The technical payment gets bundled into the payment for the line placement service—no additional technical payment is generated. An anesthe­siologist performs an ultrasound-guided axillary nerve block prior to an orthope­dic case. The physician bills the professional service for the ultrasound-guided procedure and the nerve block procedure. The hospital bundles the facility fee for the ultrasound- guidance procedure into the overall fees for the nerve block procedure.

Since 2005, CPT has dened the work required for complete and limited diagnostic ultrasounds. Complete ultrasounds include all of the structures present in an ana­tomical region and are specically listed in the CPT manual. Clinicians may bill for complete ultrasounds if medical necessity supports a complete ultrasound should take place and all of the elements required for a complete ultrasound are included in the report. For example, many clinicians are comfortable documenting all of the elements required for a complete rst trimester obstetric transabdominal ultrasound (76801). Requirements for 76801 include the following: determination of the num­ber of gestational sacs and fetuses, gestational sac/fetal measurements appropriate for gestation (younger than 14weeks 0days), survey of visible fetal and placental anatomic structure, qualitative assessment of amniotic uid volume/gestational sac shape and examination of the maternal uterus and adnexa [11]. If an element that is required by CPT for a complete ultrasound is not visualized, a reason is required. In the diagnostic ultrasound section, CPT instructs: “For those anatomic regions that have ‘complete’ and ‘limited’ ultrasound codes, note the elements that comprise a ‘complete’ exam. The report should contain a description of these elements or the reason that an element could not be visualized (e.g., obscured by bowel gas, surgi­cally absent).” [11].