Safe and noninvasive, ultrasound is being increasingly used in various medical specialties. Ultrasound is considered the appropriate imaging service to diagnose musculoskeletal (MSK) conditions, specifically shoulder pain and certain ankle and tendon pain. Medicare reimbursements for MSK ultrasound studies increased by 316% from 2000-2009. Experienced medical billing and coding companies help providers take advantage of the increased payments by staying current with the latest appropriate use criteria and reporting guidelines.
Reporting MSK Ultrasound Services – Necessary Criteria
All ultrasound examinations must:
- Meet medical necessity requirements as specified payer
- Reported 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
Medical billing outsourcing to an experienced company helps providers determine and submit claims with the appropriate codes and modifiers as well as ensure reporting of services to meet the current requirements and policies of payers.
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
Reporting CPT Code 76942 – Points to Note
- 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.
- 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:
- New CPT codes for joint injections that became effective January 2015 do not require the use of 76942:
20604 Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, 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
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
Therefore, 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 the specific setting:
– 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 office 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.
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 filed 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.
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. Partnering with an experienced medical coding company is therefore the best option to maximize reimbursement from diagnostic and therapeutic MSK ultrasound services.