Last month's column addressed the use of point-of-care ultrasound (POCUS) by hospitalists, including how the three documentation components of medical necessity, a written interpretation, and image capture and storage are needed to qualify for reimbursement.
Claims for POCUS are submitted using the Current Procedural Terminology, 4th Edition (CPT-4), codes, which distinguish between complete and limited (focused) ultrasound as well as between diagnostic ultrasound and ultrasound-guided procedures.
The CPT-4 codes for POCUS account for both a professional and a technical component. The professional component covers the clinician's services performing, interpreting, and reporting the procedure. The technical component represents the cost of the equipment, supplies, and ancillary personnel for performing the procedure.
When the clinician does not own the machine, he must append modifier 26 (professional component only) to the procedure code, which pays less than the code without a modifier. Clinicians who do not own the machines they are using are not entitled to reimbursement for the technical component of the code, which may be billed by the hospital using modifier TC. Some hospitalists may own their own handheld ultrasound device or mobile machine, in which case the POCUS code may be submitted without a modifier and will be eligible for full payment.
As discussed in last month's column, a POCUS device must be capable of storing the images and those images must be included as a part of the patient's medical record, either electronically or as printed copies. Don't forget to add modifier 25 to the code for any evaluation/management (E/M) service performed on the same day as a procedure of any kind, including POCUS.
CPT code 76942 is used for ultrasound-guided needle placement, including biopsy, aspiration, and injection, when CPT-4 has no specific code for the ultrasound-guided procedure. Code 76942 is not used for vascular procedures. It is an add-on code to be assigned along with the procedure code and is never assigned alone. Code 76937 is the add-on code for ultrasound guidance of vascular procedures when CPT-4 has no specific code that includes ultrasound guidance.
Several ultrasound-guided procedures (listed in Table 1) require an add-on code. Nontunneled central venous catheter insertion (in patients five years of age or older) is captured with codes 36556 and 76937. Ultrasound-guided diagnostic arterial puncture is coded with 36600 and 76937. Pericardiocentesis has its own add-on code, 76930, which is assigned together with the procedure code 33010. Ultrasound-guided lumbar puncture is assigned code 62270 plus 76942.
In some other procedures (also listed in Table 1), a single code is used because the code description includes the ultrasound guidance. Code 32555 is used for ultrasound-guided thoracentesis and 49083 is used for ultrasound-guided paracentesis. For arthrocentesis with aspiration and/or injection utilizing ultrasound guidance, one of three codes is assigned based on the joint size: 20604 for a small joint or bursa like fingers or toes; 20606 for an intermediate joint or bursa, including temporomandibular, acromioclavicular, wrist, elbow, ankle, and olecranon bursae; or 20611 for a major joint or bursa such as a shoulder, hip, or knee.
Table 2 lists codes for limited diagnostic POCUS, including abdominal ultrasound; screening study for abdominal aortic aneurysm; limited or unilateral duplex scan of extremity veins, including responses to compression and other maneuvers; transthoracic 2D echocardiography; and joint or other nonvascular extremity structure(s) such as joint space, periarticular tendons, muscles, nerves, other soft-tissue structures, or soft-tissue masses.
According to CPT-4, it is generally permissible for two different physicians to report a limited and a complete ultrasound on the same day, provided there is documentation of the medical necessity of the two separate procedures. For example, the limited study may be inconclusive or demonstrate abnormalities requiring a complete one. Payers' individual policies will govern reimbursement, and it's possible the limited study could be rejected in favor of the complete ultrasound. If serial limited examinations are performed on the same day, only one may be coded and billed.
In summary, coding of POCUS may involve a single or multiple CPT-4 codes. Append modifier 26 to the procedure code if the hospital owns the POCUS equipment; do not append a modifier if the device/machine is owned by the hospitalist or the group. Add modifier 25 to the code for any E/M services performed on the same day as POCUS.
Special thanks to Benjamin Galen, MD, FACP, for recommending this subject and for his assistance and suggestions in composing this column.