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22 Point ofCare Ultrasound Reimbursement andCoding
367
Pitfalls andKey Recommendations
1. Local guidelines determine which independently licensed practitioners can
obtain images to generate the PC bill for interpretation or procedural guidance.
2. Due to the mismatch between physician work and physician reimbursement, the hos-
pital and physician group should collaborate to support physician resources required
to meet governing credentialing bodies for clinician performed ultrasound.
3. Obtain legal counsel when considering billing both professional and technical
charges for ultrasound in a facility setting.
4. Medical Necessity must accompany each separate ultrasound CPT code.
Screening ultrasounds are not billable except for Abdominal Aortic Aneurysm
which received a new CPT code 76706in 2017.
5. All procedural ultrasounds require permanently archived images.
6. The TC cannot be billed without a professional component.
7. Requirements for professional ultrasound billing:
(a) Permanently recorded images
(b) Signed written diagnostic report or procedure note
(c) Documentation of missing elements for complete examinations
(d) Order
(e) Medical Necessity
Glossary/Abbreviations
Centers for Medicare and Medicaid Services (CMS)—
US federal agency which oversees Medicare, Medicaid, and Children’s Health
Insurance Program
CMS 1500—standard physician billing form
Current Procedural Terminology (CPT)—AMA publication on procedural codes
that physicians use to identify services rendered
Diagnosis-related group (DRG)—system used to categorize hospital inpatients
based on diagnosis code for reimbursement purposes.
Global codes—Codes that either 1. Cannot by denition be broken down into
professional and TC or 2. Due to the practice setting in which the procedure is
occurring, include both the professional and the TC.
International Classication of Diseases (ICD)—categorization system listing
signs, symptoms, and diseases for billing purposes
Local coverage determinations (LCDs)—CMS description of clinical utility for
a common CPT code which applies locally to providers in a particular geographic
coverage area
Medicare Administrative Contractors (MAC)—Private companies hired by CMS
to administer the responsibilities of Medicare Part A or B.
Medicare Physician Fee Schedule (MPFS)—annual publication by CMS on
RVUs and for varying CPT codes
Multiple Procedure Payment Reduction (MPPR)—bundling for radiology procedures in the same family
National coverage determination (NCD)—CMS description of clinical utility for
a common CPT code which applies nationally
368
J.R. Goldstein and S. Wu
Professional component—professional work involved in a procedure. With diagnostic ultrasound, the professional work is the interpretation of the images and creation of a report.
Prospective Payment System (PPS)—a method of reimbursement in which
Medicare payment is made based on a predetermined, xed amount. The payment
amount for a particular service is based on the DRG.
Relative Value Scale Update Committee (RUC)—multiply-specialty group
reviews RVUs for approved CPT codes.
Relative value units (RVUs)—measure of value used to weight physician services
Technical component—technical work involved in performing a procedure. With
diagnostic ultrasound, the technical component covers the cost of equipment, technician salaries, image archiving, overhead, etc.
UBO4 Form—medical insurance claim forms used by “facilities” to bill insurance companies for services rendered.
NOTE: Medicare administrative carriers frequently update their local coverage
determinations. The AMA publishes the reference book, Current Procedural
Terminology, and the Medicare Physician Fee Schedule annually. Please refer to
these references for the most up to date rules and reimbursement information.
Exhibit 1
Emergency Ultrasound Coding Guide 2017
Core emergency ultrasound codes
US study
Fast: Scan for
hemopericardium and
hemoperitoneum;
may include lung us
for pneumothorax
Intrauterine pregnancy
Pregnant uterus
limited (TA)
Pregnant uterus
complete (TA) <14
weeks
CPT
code CPT description
93308 Echocardiography, transthoracic, real-time with image
documentation (2D), with or without M-Mode
recording; follow-up or limited
76705 Echography, abdominal, B-scan and/or real time with
image documentation, limited (eg, single organ,
quadrant, follow-up)
76604 Ultrasound, chest, B-scan (includes mediastinum)
and/or real time with image documentation
76815 Ultrasound, pregnant uterus, real time with image
documentation, limted (eg fetal heart beat, placental
location, fetal position and/or qualitative amniotic
uid volume), one or more fetuses
76801 Ultrasound, pregnant uterus, real time with image
documentation, fetal and maternal evaluation,
<14weeks, single or rst gestation; complete
wRVU
2017
0.53
0.59
0.55
0.65
0.99
22 Point ofCare Ultrasound Reimbursement andCoding
369
US study
Pregnant uterus
complete (TA)≥14
weeks
Pregnant uterus
transvaginal (TV)
AAA 76775 Echography, retroperitoneal (eg renal, aorta, nodes);
Screening AAA 76705 Ultrasound, abdominal aorta, real time with image
Cardiac 93308 Echocardiography, transthoracic, real-time with image
Biliary, Bowel 76705 Echography, abdominal, B-scan and/or real time with
Thoracic, lung, or
upper back
Pelvic wall 76857 Ultrasound, pelvic (nonobstetric), B-scan and/or real
Urinary tract/Renal 76775 Echography, retroperitoneal (eg renal, aorta, nodes);
Post-void residual 51798 Measurement of post-voiding residual urine and/or
Bladder imaging 76857 Imaging of bladder anatomy, including bladder
Focused DVT study 93971 Duplex scan of extremity veins including responses to
Soft tissue ultrasound
Neck 76536 Ultrasound, soft tissues of head and neck (eg, thyroid,
Musculoskeletal
(extremities,
non-vascular),
including axilla
Chest wall 76604 Ultrasound, chest, B-scan (includes mediastinum)
Breast 76642 Ultrasound, breast, B-scan and/or real time with
CPT
code CPT description
76805 Ultrasound, pregnant uterus, real time with image
documentation, fetal and maternal evaluation, ≥14
weeks, single, or rst gestation; complete
76817 Ultrasound, pregnant uterus, real time with image
documentation, transvaginal
B-scan and/or real time with image documentation;
limited
documentation, screening study for abdominal aortic
aneurysm
documentation (2D), with or without M-Mode
recording; follow-up or limited;
image documentation, limited (eg, single organ,
quadrant, follow-up)
76604 Ultrasound, chest, B-scan (includes mediastinum)
and/or real time with image documentation
time with image documentation, limited or follow-up
B-scan and/or real time with image documentation;
limited
bladder capacity by bladder volume measurement
machine
volume measurement using an ultrasound machine
compression and other maneuvers; unilateral or
limited study.
parathyroid, parotid), B-scan and/or real time with
image documentation
76882 Ultrasound, extremity, non-vascular, B-scan and/or
real time with image documentation, limited
and/or real time with image documentation
image documentation, limited
wRVU
2017
0.99
0.75
0.58
0.59
0.53
0.59
0.55
0.5
0.58
0
0.5
0.45
0.56
0.49
0.55
0.68
370
J.R. Goldstein and S. Wu
US study
Abdominal wall or
lower back
CPT
code CPT description
76705 Echography, abdominal, B-scan and/or real time with
image documentation, limited (eg, single organ,
wRVU
2017
0.59
quadrant, follow-up)
Pelvic wall 76857 Ultrasound, pelvic (nonobstetric), B-scan and/or real
0.5
time with image documentation, limited or follow-up
Infant hip, static 76886 Ultrasound, infant hips, real time with imaging
0.62
documentation; limited, static (not requiring physician
manipulation)
Ocular 76512 Ophthalmic ultrasound, diagnostic; B-scan (with or
0.94
without superimposed non- quantitative A-scan)
Ocular FB 76529 Ophthalmic ultrasonic foreign body localization 0.57
Miscellaneous
ultrasound
76999 Unlisted ultrasound procedure (ex, diagnositc,
interventional)
0
Advanced emergency ultrasound codes 2017 (recommend advanced training)
US study
code CPT description
Advanced echo 93308 Echocardiography, transthoracic, real-time with image
CPT
wRVU
2017
0.53
documentation (2D), with or without M-Mode
recording; follow-up or limited
Transesophageal echo 93312 Echocardiography, transesophageal, real time with
2.55
image documentation (2D) (with or without M-mode
recording); including probe placement, image
acquisition, interpretation and report
Adnexal pathology
Nonpregnant uterus
TA complete
Nonpregnant uterus
TA, limited
Nonpregnant
nonuterus TV
76856 Ultrasound, pelvic (nonobstetirc), complete B-scan
and/or real time image
76857 Ultrasound, pelvic (nonobstetric), B-scan and/or real
time with image documentation, limited or follow-up
76830 Ultrasound, transvaginal (nonobstetric) and/or real
time with image documentation can be used for
1
0.5
0.69
complete or limited study
Focused duplex scan
of ovaries or testes for
torsion
US scrotum and
contents
93976 Duplex scan of arterial ino and venous outow of
abdominal, pelvic, scrotal contents or retroperitoneal
organs; limited or unilateral
76870 Ultrasound internal anatomy of scroum and scrotal
contents; to evaluate for hydrocele, azoospermia,
0.8
0.64
oligospermia, orchitis and epididymitis
Ultrasound guided procedure codes 2017
CPT
US-guided procedure
US-guided
pericardiocentesis
code Notes
76930 Requires image of site to be
1
localized but does not require
image of needle in site
wRVU
2017
Additional CPT
code
0.67 33010
22 Point ofCare Ultrasound Reimbursement andCoding
371
US-guided procedure
US guided vascular
access placement
code Notes
3
+76937
Requires written documentation
of real-time ultrasound guidance
and a representative image but
does not require image of
needle in site. This is an add- on
code and must be used in
conjuction with a primary code
CPT
US-guided
thoracentesis
2
32555 Requires image of site to be
localized but does not require
image of needle in site
US-guided
paracentesis
2
49083 Requires image of site to be
localized but does not require
image of needle in site
Miscellaneous
ultrasound-guided
procedure without
catheter—non organ
1
specic
US-guided abscess
1
drainage
76942 Requires image of site to be
localized but does not require
image of needle in site
76942 Requires image of site to be
localized but does not require
image of needle in site
US-guided
peritonsillar abscess
1
drainage
US-guided lumbar
1
puncture
76942 Requires image of site to be
localized but does not require
image of needle in site
76942 Requires image of site to be
localized but does not require
image of needle in site
US-guided
suprapubic aspiration
76942 Requires image of site to be
1
localized but does not require
image of needle in site
US-guided FB
1
removal
76942 Requires image of site to be
localized but does not require
image of needle in site
US-guided joint
aspriation
2
20604 Arthrocentesis of small joint 0.89
20606 Arthrocentesis of medium joint 1.00
20611 Arthrocentesis of large joint 1.10
Ultrasound guided regional nerve blocks
1
Femoral
76942 Requires image of site to be
localized but does not require
image of needle in site
Brachial plexus
(includes interscalene,
supraclavicular,
76942 Requires image of site to be
localized but does not require
image of needle in site
infraclavicular,
axillary, and
intercostal nerve
1
blocks)
wRVU
2017
Additional CPT
code
0.3 36000, 36555,
36556, 36557,
36558
*
2.27
2
0.67
0.67 10160 OR 10061
0.67 42700
0.67 62270
0.67 51100
0.67 10120 OR 10121
0.67 64447
0.67 64415 (brachial
plexus); 64417
(axillary), 64418
(suprascapular),
64420/64421
(intercostal)
372
J.R. Goldstein and S. Wu
US-guided procedure
1
Ulnar
CPT
code Notes
76942 Requires image of site to be
wRVU
2017
Additional CPT
code
0.67 64450
localized but does not require
image of needle in site
1
Radial
76942 Requires image of site to be
0.67 64450
localized but does not require
image of needle in site
1
Sciatic
76942 Requires image of site to be
0.67 64445
localized but does not require
image of needle in site
Saphenous
1
76942 Requires image of site to be
0.67 64450
localized but does not require
image of needle in site
1
These codes are imaging codes only. They do not include the charge for the surgical
procedure
2
These codes include both the imaging code, as well as the surgical code
3
CMS designated add-on codes are procedures that are performed in conjunction
with another primary procedure/service. These are designated by the “+” symbol in
front
Ultrasound guided procedure (leaving a catheter in place) codes 2017
US-guided procedure
code Notes
US-guided thoracentesis 32557 Thoracentesis and catheter placement. Requires
image of site to be localized but does not
require image of the needle in site
CPT
Image guided uid
collection drainage by
catheter, soft tissue
10030 (eg, abscess, hematoma, seroma, lymphocele,
cyst), soft tissue (eg, extremity, abdominal wall,
neck), percutaneous, includes moderate sedation
when used. Must leave catheter in place for
drainage. Requires image of site to be localized
but does not require image of needle in site
Image guided uid
collection drainage by
catheter, visceral
percutaneous
49405 (eg, abscess, hematoma, seroma, lymphocele,
cyst), visceral (eg, bladder), percutaneous,
includes moderate sedation when used. Must
leave catheter in place for drainage. Requires
image of site to be localized but does not
require image of needle in site
Image guided uid
collection drainage by
catheter, peritoneal/
retroperitoneal percutaneous
approach
49406 (eg, abscess, hematoma, seroma, lymphocele,
cyst), peritoneal/retroperitoneal percutaneous,
includes moderate sedation when used. Must
leave catheter in place for drainage. Requires
image of site to be localized but does not
require image of needle in site
Image guided uid
collection drainage by
catheter, peritoneal/
retroperitoneal transvaginal/
49407 (eg, abscess, hematoma, seroma, lymphocele,
cyst), peritoneal/retroperitoneal transvaginal/
transrectal includes moderate sedation when
used. Must leave catheter in place for drainage
transrectal approach
wRVU
2017
3.12
2.75
4.00
4.00
4.25
22 Point ofCare Ultrasound Reimbursement andCoding
Separately billable CPT codes for ultrasound guided procedures (in numerical order)
CPT code Description wRVU 2017
10120 Incision and removal foreign body simple 1.22
10121 Incision and removal foreign body complicated 2.74
10160 Incision and drainage of abscess simple 1.25
10061 Incision and drainage of abscess complicated 2.45
33010 Pericardiocentesis, initial 1.99
36000 Place needle in vein 0.18
36555 Insertion of non-tunneled central venous catheter age <5 YO 2.43
36556 Insertion of a non-tunneled central venous catheter agE >5 YO 2.50
36568 Insertion of a non-tunneled picc age <5 YO 1.67
36569 Insertion of a non-tunneled picc age >5 YO 1.82
42700 Drainage of tonsil or peritonsillar abscess 1.67
51100 Aspiration of bladder by needle 0.78
62270 Diagnostic lumbar puncture 1.37
Disclaimer: wRVU are for 2017 only and may change in future years
373
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J.R. Goldstein and S. Wu
Chapter 23
Global Medicine Perspectives
SachitaP.Shah
Objectives
• Describe ultrasound program management issues encountered in limited resource
settings including low and middle-income countries (LMICs), and rural, austere
settings
• Desired features of ideal equipment and maintenance plans
• Step by Step strategies for program implementation including needs assessment,
education program options, interdisciplinary approach, and sustainability
• Funding, billing and infrastructure in LMICs
• Unique safety and supply chain considerations including gel, sanitation, and
storage
Introduction
As the eld of clinical ultrasonography continues to grow, there has been a rapid
expansion in new applications of point of care ultrasound (POC US) in global and
rural health. Diseases cited as the leading causes of death in low and middleincome countries (LMICs) each have ultrasound-diagnosable features (Fig.23.1)
and the growth of POC US use globally has garnered interest of major stakeholders in global health such as the World Health Organization (WHO) [1], high impact
nonprot organizations (e.g., Partners In Health [2], Medecins Sans Frontieres [3],
International Medical Corps [4]), and ministries of health (e.g., Rwanda Medical
Council Continuing Professional Development course [5]). While some
S.P. Shah, MD, FACEP
Department of Emergency Medicine, University of Washington,
Harborview Medical Center, Seattle, WA, USA
e-mail: sachita.shah@gmail.com
V. S. Tayal et al. (eds.), Ultrasound Program Management,
https://doi.org/10.1007/978-3-319-63143-1_23
375© Springer International Publishing AG 2018
376
Lower Respiratory Infections
Deaths per 100,000 population (WHO 2012 Low Income Countries)
0255075 100
S.P. Shah
Pneumonia
Ischemic Heart Disease
Preterm Birth Complications
Fig. 23.1 Ultrasound for Identication of Top Causes of Mortality. Source http://www.who.int/
mediacentre/factsheets/fs310/en/index1.html
ultrasound program management principles are applicable globally, a thoughtful
and unique approach to expansion of POC US to LMIC’s and even within rural,
underserved areas of the United States should be used. New programs for ultrasound training are increasing in frequency, and a recent website www.globalsono.
org, sponsored by an ACEP (American College of Emergency Physicians) section
grant, is attempting to connect and register all POC US programs in LMICs
(Fig.23.2. GlobalSono.org Map of registered programs for POC US education in
LMICs).
POC US, or use of sonography by the treating clinician, appears to be the main
method of rapid expansion for ultrasound use worldwide. This is multifactorial,
including the worldwide shortage of radiologists and sonographers [6, 7], general
barriers to patient transport for imaging studies from rural areas to higher level of
care in LMICs with poor infrastructure, and lack of access to advanced imaging such
as computed tomography (CT). For example, in the West African country of Liberia,
population 4.3 million with only 50–150 practicing physicians in the country only a
handful of whom are specialists of any kind, there is frequently not a single functioning computed tomography (CT) or Magnetic Resonance Imaging (MRI), making
ultrasound the most detailed level of diagnostic imaging available for millions. The
WHO has suggested that ultrasound is the ideal imaging modality for limited resource
settings due to its versatility for diagnostic use, and increasing portability, affordability, and durability. In 1998 the WHO published consensus- based, ultrasound
HIV/AIDS
Diarrheal disease
Stroke
Malaria
Tuberculosis
Birth Asphyxia
Viral CM, Nephropathy, DVT
IVC Volume Assessment
Echo, Carotids
Echo WMA
Splenomegaly, ONSD
Multiple Gestation, Placenta previa, Cervical
Insufficiency
Pleural/Pericardial Effusions, Ascites, Organ
Infiltration
Pelvic Disproportion, Breech Presentation