Coding Corner

Coding and Documentation for Ultrasound Use in the ICU

George A. Sample, MD*
Senior Attending, Critical Care
Washington Hospital Center
Washington, DC, USA

Val Veitengruber, CPC, CMSCS, CHCO**
Reimbursement Manager
SonoSite, Inc.
Bothell, Washington, USA

Point-of-care ultrasound use is increasing in critical care settings, particularly its application in needle visualization and real-time guidance for procedures. As with all medical procedures, it is important to document and report the service accurately. To avoid denials in this particular area, one must demonstrate medical necessity and use the most specific Current Procedural Terminology (CPT) and ICD-9 coding. Practitioners must provide documentation via the physical examination to support diagnostic scans as well. While the medical record or ultrasound report is not submitted with the claim, third party payors may request to review this material at any time. Meticulous documentation is required to support claims and, in case of an audit, to avoid refunds and/or penalties.  

This Coding Corner outlines how to document and report procedures related to ultrasound-guided central line placements and thoracentesis. Ultrasound can increase accuracy and decrease mechanical complication in these procedures, and should be considered when possible.

When ultrasound is used for guidance of central line placements, the recommended CPT code is:

+76937 – Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting (see Table 1).

To meet the requirements of reporting this code, providers must produce and retain permanent images of the ultrasound study. The images may be maintained in either electronic or hard-copy format. Additionally, a written report of the study must be maintained in the patient record, either as a separate item or within the report for the line placement itself. Additionally, the description of the guidance process should be included in the final written report.

This CPT code is an “add-on” code, which means it is billed in conjunction with the procedure for the type of central venous access device placed, which typically includes codes in the 36555-36585 range.

In all reporting of ultrasound services in the hospital setting, the physician’s professional service is identified by appending the -26 modifier to the appropriate CPT code, i.e., 36556, 76937-26. This indicates to the payers that you have provided the professional component of the ultrasound service, which encompasses the supervision and interpretation elements.

When this CPT code was established in 2004, the American Medical Association’s book, CPT® Changes: An Insider’s View, provided the guidance that +76937 included the pre-access ultrasound assessment for vessel patency and the actual real time guidance of the needle. This code should not be reported if ultrasound is used only to locate the vein and mark the entry point. Ultrasound is also commonly used to evaluate the pleural spaces for the presence of fluid and/or masses of the chest, chest wall or mediastinum.

This CPT code is: 76604 - Ultrasound, chest (includes mediastinum), real time with image documentation (see Table 2).

When fluid is found and a thoracentesis is required (and ultrasound is utilized to guide the procedure), the ultrasound guidance code also is reported with the appropriate thoracentesis coding:

76942 - Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation (see Table 3).

This is billed with either:
32421 - Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent
OR
32422 -Thoracentesis, with insertion of tube, includes water seal (e.g., for pneumothorax), when performed (separate procedure)

An example of the physician’s professional coding of the ultrasound guidance of an initial
thoracentesis is 32421 and 76942-26.

In cases where a chest tube insertion is needed, a different type of guidance code is reported:
75989 – Radiological guidance (i.e., fluoroscopy, ultrasound or computed tomography) for percutaneous drainage (e.g., abscess, specimen collection)

This is billed with either:
32550 – Insertion of indwelling tunneled pleural catheter with cuff
OR
32551 – Tube thoracostomy, includes water seal (e.g., for abscess, hemothorax, empyema), when performed (separate procedure)

As with the documentation requirements for the guidance of line placements, ultrasound used for the above procedures requires permanently recorded images and a written description of the process. For the evaluation of the pleural spaces for fluid, both a separate ultrasound report and the images are required.

George Sample, MD, from Washington Hospital Center in Washington, D.C., is the special guest editor for Coding Corner. Coding text reprinted with permission from SonoSite, Inc.

Disclosures:

* Author has no disclosures to report

**Author is an employee of SonoSite, Inc. as a coding and reimbursement expert