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Bedside US

Regina Posted Wed 11th of April, 2012 12:57:42 PM

I would like other opinions on CPT for bedside ultrasound and is this appropriate documentation to code an ultrasound? CT abdomen and pelvis. Note reads: ED bedside ultrasound, portable. Indication--mass found in abdomen, finding enlarged uterus. Impression--could be due to fibroid.

SuperCoder Answered Thu 12th of April, 2012 07:57:43 AM

76700 for complete. Usually in ED we bill US Fast i.e; 76705

Documentation:

Interpretation. Facilities are required to maintain a written interpretation and report in the patient’s medical record. That must describe the structures or organs studied and supply an interpretation of the findings. The report needs to clearly identify who performed the procedure and who interpreted the results. In some cases, a sonographer may perform the scan and then a physician interprets it.
Medical necessity. The medical necessity for the test must be documented by the physcians.
Image retention. Facilities must permanently story appropriate image(s) of the relevant anatomy and pathology for future review. An image is now required for all procedures performed with an ultrasound.
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Append appropriate modifiers for FAST exams
The ultrasound report also needs to fully describe whether the ultrasound exam was a complete or limited study or a repeat examination by the same physician, a repeat examination by a second physician, and/or a reduced level of service.

Modifiers are a necessary component for complete billing documentation. The following modifiers will paint the picture of the service you are reporting:

-26 (professional component only)
-TC (technical component only)
-52 (reduced services)
-59 (distinct procedural service)
-76 (repeat procedure by same physician)
-77 (repeat procedure by another physician)
When coding for the FAST ultrasound, it’s important to understand the differences between a limited exam and a complete exam.

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