Medical Documentation Requirements: Diagnostic Urologic Ultrasound and Ultrasound-Guided Procedures

Over the past several years, physicians have requested guidance from both the AUA and the American Institute of Ultrasound in Medicine (AIUM) on the proper documentation of ultrasound services. The AUA provides information on ultrasound examinations used by urologists and the proper documentation requirements of Current Procedural Terminology® (CPT®) guidelines to report the codes for reimbursement.

The AUA and the AIUM recommend adequate documentation of ultrasound exams to provide high-quality patient care. Taking the extra necessary measures to document diagnostic ultrasound exams and ultrasound-guided procedures will limit unnecessary audits and potentially stressful litigations.

Introduction

Diagnostic ultrasound imaging has been an integral part of urologic medicine for many years. Providing the best care is of utmost importance to the AUA and the AIUM. Quality patient care can be defined in many ways. However, a very important piece is documentation of ultrasound exams. 

Diagnostic ultrasound studies and ultrasonic guidance procedures include both a technical component (TC) and a professional component (PC). The technical component is the performance of the test and acquisition of images, while the professional component is the interpretation of the test and creation of a detailed written report. It is necessary to have copies of the ultrasound images in the patient's medical record as proof the procedure was performed. For example, when performing a transrectal ultrasound, include a copy of the image in the chart. The same holds true for ultrasound guided procedures for needle placement. An image showing the needle in the area where the biopsy tissue was taken is needed for proper documentation.

There are several ultrasound services that may be performed by urologists. The CPT® codes include the following:

Coding and Billing for Diagnostic Ultrasound and Ultrasound-Guided Procedures

In order to report the appropriate CPT® code(s) for services provided, the services must be documented appropriately including both the images (TC) and the report (PC). This type of documentation must be in the patient’s chart. With regard to CPT® descriptors for radiography services, "images" refers to those acquired in either an analog (ie, film) or digital (ie, electronic) manner.

For billing purposes, the technical component should be billed by the entity that owns the machine, while the professional components should be billed by the interpreting provider. Imaging is reported and reimbursed globally (TC and PC together) if performed and interpreted by the same provider at the same setting. However, the TC and PC can be billed separately if the images are acquired on one day and interpreted on a separate day, or if the interpreting provider does not own the machine (for example, if a provider is using hospital-owned equipment). In the latter case, the performing and interpreting provider must coordinate billing with the hospital, and the interpreting provider will append the CPT® code with the professional component modifier (-26) while the hospital adds the technical component (-TC) modifier.

Limited vs. Complete Ultrasound

Ultrasounds can be classified as complete or limited as indicated in the CPT® code descriptor. To bill for a complete examination, all items and organs listed must be imaged and described, or reason an organ is not imaged or described (ie, organ surgically absent) documented. For example, to bill for CPT® 76856 Ultrasound pelvic (nonobstetric), or real time with image documentation; complete evaluation and measurement (when applicable) of the urinary bladder, evaluation of prostate and seminal vesicles (visualized transabdominally), and any pelvic pathology (bladder tumor, enlarged prostate, free pelvic fluid, pelvic abscess) must be performed.

In addition, there are some guidelines in the CPT® manual for codes that are performed at the same time.  For example, when an abdominal ultrasound and pelvic ultrasound are performed to evaluate the kidneys and bladder, technically both a 76705 Ultrasound abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) and a 76857 Ultrasound, pelvic (nonobstetric), real time with image documentation, limited or follow-up (ie, for follicles) are performed to evaluate each of these organs. However, the American Medical Association has determined that CPT® code 76770 Ultrasound, retroperitoneal (ie, renal, aorta, nodes), real time with image documentation, complete should be billed if the clinical history suggests urinary tract pathology, and evaluation of both kidneys and bladder.

Ultrasound Documentation Requirements

The AIUM recommends utilizing the Practice Parameter for Documentation of an Ultrasound Examination in order to provide high-quality patient care. As explained in this practice parameter, “there should be a permanent record of the ultrasound examination and its interpretation.” Details, regarding making sure that images are stored in a retrievable format, documenting the ultrasound examination in written report with accompanying images, and having this report be available by the next business day are just a few of AIUM’s recommendations found in the above parameter. The minimum documentation required by CPT® is a separate summarized written paragraph documented in the patient's chart with any permanently recorded images (with measurements when clinically indicated) and all anatomic areas imaged must be described.

Many offices and hospitals are now using a picture archiving and communication system (PACS) for short- and long-term storage, retrieval, management, distribution, and presentation of medical images. However, if your practice does not have a PACS, copies of ultrasound images must still be maintained in the electronic health record or in the patients chart. For billing purposes, having the images stored on a PACS satisfies reporting requirements. Also, making sure that images are stored in the patient’s medical chart or PAC system can prevent legal and reimbursement issues in the future. If chart audits are performed by the insurance company and no documentation of the ultrasound (images and report) is in the chart or in the PAC system, money paid on the claim can be requested as well as trigger a larger audit. In addition, a possible litigation could prove detrimental to the physician if request for documentation cannot be provided.

The language describing the written report has recently been revised to reflect the increased use of electronic reporting, as described in the introductory guidelines of the radiology section of the 2016 CPT® manual:

“A written report (eg, handwritten or electronic) signed by the interpreting individual should be considered an integral part of a radiologic procedure or interpretation.”

Imaging Performed on the Same Day as an Encounter

The American Medical Association clarified that if an imaging test is performed on the same day as an Evaluation & Management (E&M) service, that each should be separately documented and billed, as stated in the E&M Services Guidelines Section in the CPT® book:

"The actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E&M services. Physician performance of diagnostic test/studies for which specific CPT® codes are available may be reported separately, in addition to the appropriate E&M code. This physician interpretation of the results of diagnostic tests/studies with preparation of a separate, distinctly identifiable signed written report may also be reported separately, using the appropriate CPT® code with the modifier -26, Professional Component, appended.”

In addition in the radiology section’s guidelines under “supervision and interpretation,” the following describes the requirements for documentation:

“Imaging may be required during the performance of certain procedures or certain imaging procedures may require surgical procedures to access the imaged area. Many services include image guidance, which is not separately reportable and is so stated in the descriptor or guidelines. When imaging is not included in a surgical procedure or procedure from the Medicine section, image guidance codes or codes labeled “radiological supervision and interpretation” may be reported for the portion of the service that requires imaging. Both services require image documentation and radiological supervision, interpretation, and report services require a separate interpretation.”

Image guidance may be included in the operative report for the procedure for which the guidance was performed. It does not have to have a separate written report but a separate image is required in the chart to show that the guidance (with the needle, etc.) is being used. The AIUM also includes a description regarding Reporting of Ultrasound-Guided Procedures within the Practice Parameter for Documentation of an Ultrasound Examination.

Insurance Provider information

Many individual insurers accept the AIUM’s Practice Parameter for Documentation of an Ultrasound Examination as the standard for reporting an ultrasound exam. However, individual insurers could have their own requirements as to whether the report should be documented on a separate piece of paper in the patient's chart or commented on separately in the office notes or operative notes. 

Although, insurer payment policies can vary plan to plan, the following health plans currently require accreditation in urology for certain ultrasound codes listed above:

• Emblem/HIP
• Horizon BCBSNJ (effective 9/7/17)
• Wellcare, NY (effective 1/1/17)

AUA has additional information on practice accreditation and more is available via the AIUM.