Ultrasound Guidance Billing Codes
Ultrasound Guided Injection – CPT Codes
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Coding Musculoskeletal Ultrasound Guided Procedures
(Last checked August 2020)( Please note that OHIP ultrasound billing guidance is included on the EMG/STIM guidance billing page)
Ultrasound is considered the appropriate imaging service to diagnose:
- Musculoskeletal (MSK) conditions
- Specialty shoulder pain
- Certain ankle and tendon pain.
Reporting MSK Ultrasound Services:
The necessary criteria all ultrasound examinations must:
- Meet medical necessity requirements as a specified payer
- Report using codes that provide the highest degree of accuracy and completeness
- Be documented in the patient’s record, regardless of the type of ultrasound equipment that is used
CPT Codes for MSK Ultrasound Evaluation:
Coding for diagnostic MSK ultrasound requires an understanding of CPT codes 76881, 76882 and 76942:
76881 Ultrasound, extremity, non-vascular, real time with image documentation; complete
76881 describes a complete examination which includes the examination and documentation of the muscles, tendons, joint, and other soft tissue structures and any identifiable abnormality of the joint under evaluation.
76882 Ultrasound, extremity, non-vascular, real time with image documentation; limited, anatomic specific
76882 is used when the assessment is a limited examination of the extremity where a specific anatomic structure such as a tendon or a muscle, or the code is used to evaluate a soft-tissue mass.
76942 Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation
76942 is used to report the application of ultrasound to guide injections or aspirations, that is, ultrasonic guidance for needle placement, such as biopsy, aspiration, injection, or localization device, as well as imaging supervision and interpretation. 76942 should be reported in addition to the code for the underlying procedure.
Centers for Medicare & Medicaid Services (CMS) payment policy allows one unit of service for 76942 at a single patient encounter regardless of the number of needle placements performed. Per the National Correct Coding Initiative (NCCI), the unit of service for this code is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.
The physician should not report a diagnostic ultrasound CPT code and CPT code 76942 (ultrasonic guidance for needle placement...) when performed in the same anatomic region on the same date of service.
76942 requires that ultrasound imaging is used to guide the needle such as for a needle biopsy or fine needle aspiration (FNA) of an organ or body area, though it is not required that the ultrasound guidance be used specifically for the insertion of the needle through the skin.
According to the Radiology section of the NCCI, “Ultrasound guidance and diagnostic ultrasound (echography) procedures may be reported separately only if each service is distinct and separate”. MSK procedures that may be ultrasound guided and for which 76942 should be reported in addition include:
20526 Injection, therapeutic (e.g., local anesthetic, corticosteroid) carpal tunnel
20527 Injection, enzyme (e.g., collagenase) palmar fascial cord (Dupuytren’s cord) post enzyme injection
20550 Injection(s) single tendon sheath, or ligament, aponeurosis (e.g., plantar “fascia”)
20551 Injection(s) single tendon sheath, or ligament, aponeurosis (e.g., plantar “fascia”) single tendon origin/insertion
20552 Injection(s), single to multiple trigger point(s) one or two muscle(s)
20553 Injection(s), single to multiple trigger point(s) three or more muscle(s)
20612 Aspiration and/or injection of ganglion(s) cyst any location
New CPT codes for joint injections that became elective January 2015 do not require the use of 76942:
20604 Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, ngers, toes); with ultrasound guidance, with permanent recording and reporting
20606 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow, or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting
20611 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting
76942 can be used only specific injections, when the terminology “with ultrasound/ image guidance” is not included in the injection CPT code descriptor.
Modifier Use is Based on Specific Settings
- In the office setting, the physician who owns the equipment and perform the service himself/herself or through an employed or contracted sonographer may bill the global fee without any modifiers. However, if billing for a procedure on the same day as an oce visit, -25 modifier must be used (though not routinely). This indicates “[a] significant, separately identifiable evaluation and management service.”
- In a hospital setting, modifier -26 must be CPT code for the ultrasound service to indicate that only the professional service was provided. Payers will not reimburse physicians for the technical component in the hospital setting.
Documentation Requirements
Physicians should provide documentation to support the medical necessity for the diagnostic ultrasound examinations including those which require ultrasound guidance. A written report of all ultrasound studies as well as permanently recorded images should be led in the patient record.
Though they do not need to be submitted with the claim, documentation of the study must be available to the insurer upon request. For ultrasound guidance, the written report may be maintained separately in the patient’s record or it may be included within the report of the procedure for which the guidance was used.
Reimbursement
Most medical insurance plans cover ultrasound studies when they are indicated as medically necessary. However, Medicare and private payers may have different requirements. Private insurance payment rules vary by payer and plan as regards which specialties can perform and receive reimbursement for ultrasound services.
Ultrasound providers face risk of denied claims and even audits if they are not knowledgeable about coding and billing rules and payer guidelines.
Please feel free to contact us should there be any comments about billing, to help us update this page.
MSK Ultrasound Reimbursement Guide (2021)
A) Reimbursement Pathway
- Determine which path of reimbursement to use by defining the circumstances and site of service for the Ultrasound procedure.
- Ultrasound examinations performed using mobile ultrasound may be reported using the same CPT® codes applicable to traditional ultrasound systems provided that all applicable requirements are met.
- These requirements include without limitation: documentation in the patient record, appropriate level of completeness, medical necessity (determined by the payer) and accurate CPT® code selection.
If these requirements are not met, and/or a follow-up ultrasound exam is ordered to determine the diagnosis, the ultrasound exam is considered part of the patient’s initial Evaluation and Management (E/M) examination and may be billed accordingly.
B) Personnel Qualifications
Ensure all personnel qualification and documentation criteria are met, per the payer guidelines, the American Medical Association and your local Medicare contractor:
- These criteria tend to be distinct to Medicare, local payers, as well as individual institutions. and should be followed in strict accordance.
- In general, guidelines require that the examinations be performed within the scope of the physician’s state license.
- Note that some insurers require physicians to submit applications requesting ultrasound be added to their list of services performed at that institution.
Documentation:
- The ultrasound procedure/s should be recorded in the permanent patient medical record, including the reason for the exam, and findings.
- Images should be appropriately labeled and appropriately identified.
- If possible, a copy of the image should be included in the medical record.
- As per CPT guidelines, a written report signed by the interpreting individual should be considered an integral part of a radiologic procedure or interpretation.
Bundled services:
Many procedures involve ultrasound imaging and consequently the imaging is included in the CPT code description. Be sure to review the CPT code to determine if the imaging is included or if it may be eligible for separate coding and billing.
Site of Service:
- Consider the optimal site of service for the ultrasound procedure mindful of the fact that some services are not covered in the ASC (Ambulatory Surgery Center) setting or are reimbursed at a substantially lower rate.
- Medicare’s calculation of ASC services is complex, involving historical billing data from physician office settings versus hospital outpatient settings.
C) Preauthorization
- Consider pre-authorizing the procedure with the patient’s payer. Payers will typically require information on the patient’s diagnosis or symptoms and the CPT procedure code for the intended and appropriate ultrasound procedure.
- Billing occurs according to payer requirements using appropriate and accurate Current Procedural Terminology (CPT) and ICD-10-CM Coding. Some payers allow electronic claims filing, while other payers require manual claims filing. Note: Generally, Medicare does not preauthorize services.
D) Track the claim
Track billing and appeal any denied and/or underpaid claims.
- The following guide provides coding and payment information for diagnostic ultrasound and related ultrasound-guided procedures.
- Payment rates are calculated based on current Medicare fee schedules. Private payers and Medicaid agents may pay more or less than Medicare.
- This information was obtained from third-party sources, and is subject to change without notice, as Medicare and other payers may change their reimbursement policies at any time. the information provided.
Disclaimer
The information provided herein is gathered from third-party sources and is subject to change. It is intended to serve as a general reference guide and should not be considered reimbursement or legal advice.
For all coding, coverage and reimbursement matters or questions, please consult your third- party payers, certified coders, reimbursement specialists and/or legal counsel.
Please note, the use of any particular code(s) will not guarantee coverage or payment at any specific level. Coverage for these procedures may vary by payer.
Please feel free to contact us should there be any comments about billing, to help us update this page.