Volume 5, #1

February 2008

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Ultrasound in the Emergency Department

Ann Florer, RN, BSN, CCS-P
Corporate Compliance Analyst

As ultrasound technology becomes an increasing standard practice in emergency medicine, growing numbers of Emergency Department Physicians (EP) are being trained and credentialed to perform ultrasound studies. The American College of Emergency Physicians (ACEP) published a Policy Statement on Emergency Ultrasound Guidelines in 2001. These guidelines firmly supported the need for emergency ultrasound on a 24 hour basis and that EP should perform such exams. The ACEP policy statement described the scope of practice for emergency ultrasound examination: they are usually being performed at the bedside to answer a single, focused question within minutes, as well as appropriate pathways for completion of EP training.

The practice of EP performing ultrasounds has not been without controversy, however. Initially several Centers for Medicare & Medicaid Services (CMS) contractors stated that these ultrasounds were an extension of the physician's physical exam and thus any reimbursement was to be part of the evaluation and management (E/M) service. In addition, the evolving technology of small handheld ultrasound devices also created some debate. Again several CMS contractors wrote coverage determinations that stated such hand held ultrasounds "are an extension of the physical exam and are not intended to replace standard ultrasound studies. The studies allow only a limited view of structures and the quality of tests performed by minimally trained physicians (including non-cardiologists) is not comparable to that obtained by standard machines."

Following ACEP written protests, in 2003 many payers and CMS Carriers reversed their position on handheld ultrasounds. One CMS Carrier stated the following: "Medicare recognizes that the miniaturization of electronic devices is an on-going trend that may be associated with either improved or diminished test performance. The appropriate assignment of a specific ultrasound CPT^® code is not solely determined by the weight, size, or portability of the equipment, but rather by the extent, quality, and documentation of the procedure. "

Any remaining controversy regarding EP performance of ultrasounds continues to center around reimbursement. Payers no longer focus on who performs the ultrasound procedure or what type of ultrasound device is used, but on the quality of the study performed, the documentation of the procedure and the medical necessity for it. In fact, the Office of Inspector General (OIG), in its 2008 Work Plan, will be reviewing services and billing patterns in geographical areas with high utilization of ultrasounds paid under the Medicare Physician Fee Schedule for medical necessity.

Over the past several years, the CPT^® code book has made several changes or additions impacting the particular codes used to assigned ultrasounds. These include the appropriate use of "complete" versus a "limited" ultrasound code, the requirement that all ultrasound procedures require image storage or archiving to assign the code, and, in 2008, language indicating that these codes specifically require an interpretation of the data, images, and slides (i.e. the results).

Medicare provides the following minimum criteria for assignment of ultrasound service:

• It must be medically reasonable and necessary for the diagnosis or treatment of illness or injury.
• It should be done for the same purpose as a reasonable physician would order a standard ultrasound examination.
• It must be billed using the CPT code that accurately describes the service performed.
• The technical quality of the exam must be in keeping with accepted national standards and not require a follow-up ultrasound examination to confirm the results.
• The study must be performed and interpreted by qualified individuals.
• The medical necessity, images, findings, interpretation, and report must be included.

An EP predominantly performs "limited" ultrasounds. However, not all ultrasounds have both a CPT limited or complete code, and the Focused Assessment by Sonography for Trauma (FAST) is actually two separate limited studies (a limited transthoracic echocardiography and a limited abdominal). The following presents an overview of necessary documentation needed in order to compliantly assign the professional portion (interpretation and report) of ultrasound services, as well as support the medical necessity for the test.

Findings, relevant clinical issues, and comparative data

The interpretation and report should be similar to that which would be prepared by a specialist in the field (for example, a radiologist). The report must be a separately identifiable written report although it does not have to be on a separate piece of paper. The American College of Radiology guidelines state the body of the report should include procedures and material, findings, limitations (if any), clinical issues and comparative data (if available). It should be clear who the interpreting physician is via a legible signature or initials, an electronic signature, etc.

i. A description of the studies and statement of who performed the studies. For example, "I performed a limited abdominal ultrasound."

ii. A specific description in precise anatomic language of the organ or body area evaluated. For example, "I performed a limited abdominal ultrasound of the gallbladder and common bile duct to evaluate for choleliths and choledocholithiasis in a 47 year old female with weight loss, moderate RUQ pain, and an elevated amylase and LFTs."

iii. An accurate description of the specific location and extent of any positive or pertinent negative findings. For example, "The gallbladder was visualized without difficulty, no stones were seen. The common bile duct is thickened and appears dilated and partially blocked with what I suspect is a cancerous growth."

iv. Impression or conclusion, including a precise diagnosis, which may include differential diagnosis as appropriate, or what was suspected versus what was found. For example, "Suspect adenocarcinoma of the pancreas. Patient will require additional testing and workup."

References

Diagnostic Radiology, Trailblazer, a CMS contracted Intermediary and Carrier, Written Interpretation and Report Documentation, page 31

ACEP, Emergency Ultrasound Coding and Reimbursement Update-2007, Stephen Hoffenberg, MD, FACEP, Jessica Goldstein, MD

Noridian Administrative Services, LLC. CMS Carrier for states of Alaska, Arizona, Colorado, Hawaii, Iowa, Nevada, North Dakota, Oregon, South Dakota, Washington and Wyoming. Article for Hand-Carried Ultrasound (A23254), 04/01/2003

ACEP, Emergency Ultrasound Coding and Reimbursement

ACEP Emergency Ultrasound Guidelines—2001

HealthNow Upstate Medicare Division, NY, March 2003 Medicare B Hotline Bulletin Hand Carried Ultrasound Examinations