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Ultrasonography in Critical Care

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Point-of-care, focused evaluation ultrasonography is increasingly used in critical care settings as it becomes part of the standard of care for critical care medicine.

Examples of specific applications include:

• Focused volume status evaluations
• Abdominal studies
• Focused cardiac studies
• Pulmonary applications
• Procedures using real-time ultrasonic guidance and needle visualization

As with all medical interventions, it is important to document and report the service accurately. To avoid denials, all the following elements must be demonstrated:

• Medical necessity: Indicate why the test was medically necessary.
• Interpretation: Add a written interpretation and reportto the patient’s medical record describing pertinentstructures and organs and interpretation of the findings.
• Image retention: Permanently store an appropriate image (still or videoclip) with measurements, when clinically indicated, for future review.
• Appropriate coding: Use the most specific Current Procedural Terminology (CPT®) and International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) codes.

Practitioners should provide documentation within their evaluation and management note to support any diagnostic scans. Third-party payers can request to review this material (including physical proof of documented images) at any time.

All ultrasonography codes require permanently recorded images to be retained and stored, either in the patient’s record or in another archive. The format can be a hard-copy printout or a retrievable electronic version. CPT® does not specify how the images should be stored or how many images are required for a given study.

A separate written interpretation for ultrasonic examinations is required to be maintained in the patient’s medical record. This documentation should include clinical indication, the name of the imaging clinician, ultrasonography findings and interpretation, and the name of the interpreting clinician. A clarifying statement regarding the scope of the examination should also be included (e.g., “limited” or “complete”).

Most bedside ultrasonic examinations for critical care medicine can be considered limited because they focus on a specific point-of-care clinical inquiry.

In the case of ultrasonic guidance procedures, the written report may be filed as a separate item in the patient’s record or it may be included in the report of the procedure for which the guidance was used.

Radiology codes, including those for ultrasonic procedures performed at the bedside in critical care units, are divided into diagnostic codes and procedure guidance. Diagnostic codes refer to the specific examination the practitioner performed (e.g., abdominal ultrasonic evaluation or pleural ultrasonic evaluation).

An example of a diagnostic study is the evaluation of pleural spaces for fluid. Code 76604 is for ultrasound, chest (includes mediastinum), real time, with image documentation. In this situation, only one CPT® code is listed.

For billing purposes, ultrasonography codes have two components: technical and professional. The two components make up the “global” service. For many of the ultrasonic procedures performed in the hospital setting, the professional component is identified by appending modifier 26 to the CPT code.

For example, a pleural ultrasonography performed in the ICU is reported as code 76604-26 (ultrasound, chest, with ultrasound services provided at the hospital). The professional component includes physician work such as a written interpretation and supervision of the ultrasonic study.

The technical component is reported under the billingfacility and conveys the costs associated with the performance of the study, such as equipment, facility use, nonphysician labor costs, and supplies. The physician cannot bill third-party payers for technical services provided in
the hospital. In these settings, the physician may submit only the professional component; the facility submits the appropriate charge for the technical service.

Another modifier pertinent to the practice of critical care medicine refers to a repeat—or serial—ultrasonic evaluation. An example of a repeat evaluation is evaluation of volume status when a patient’s clinical condition is deteriorating (e.g., concern for clinical progression of an aortic abdominal aneurysm). The appending modifiers 76 and 77 are both used for repeat procedures when performed on the same date of service. Modifier 76 is used when the same service is provided by the same physician on the same date, whereas modifier 77 is used when the same service is provided by a different physician on the same date.

Evaluation of Volume Status/Abdominal Ultrasonography
Volume status and cardiac output can be evaluated by the placement of an esophageal Doppler monitoring device. Clinical indication is approved for ventilated patients in the ICU for continuous monitoring as well as intraoperative volume management.

Bedside limited ultrasonic studies also can be used for evaluation of volume status. Several ultrasonography protocols for evaluation of a critically ill patient, such as focused assessment with sonography in trauma (FAST), rapid ultrasonography in shock (RUSH), and focused
assessed transthoracic echocardiography (FATE) have been published. Specific CPT codes do not exist for these evaluations. Instead, a combination of limited ultrasonic evaluation codes should be used (with modifier 26) that appropriately encompass the scope of the performed bedside ultrasonic study.

Example of a FAST Examination
CPT 93308: Limited transthoracic echocardiography
• Focused echocardiographic evaluation
• Pericardial fluid
• Component of FAST examination
CPT 76705: Limited abdominal ultrasonography
• Biliary tract disease
• Quadrant evaluation
• Ascites evaluation
• Component of FAST examination
CPT 76775: Limited retroperitoneal ultrasonography
• Aorta evaluation
• Renal imaging
In cases in which both the cardiac views and abdominal views are obtained as part of the FAST examination, both CPT® codes 93308-26 and 76705-26 may be reported.
American Medical Association. 2018 Current Procedural Terminology Professional Edition; American Medical Association, Chicago, IL., 2018.
Centers for Medicare and Medicaid Services. Internet-Only Manuals. Publication 100-4. Medicare Claims Processing Manual. 12. Washington, DC: Centers for Medicare and Medicaid Services; 2017:chapter 12.
Centers for Medicare and Medicaid Services. National Correct Coding Initiative Edits. Washington, DC: Centers for Medicare and Medicaid Services; 2018.