Point Of Care Ultrasound In The ER

Quest ion:

We have a provider who is a Physician Assistant (PA) doing ultrasounds in the ERsetting. He is not running a report to show that he has done this, and there is no CPT®code for this service at this time. But if he is a certified ultrasound tech, runs the ultrasound report and we have the radiologist read the report and get a CPT®code for the ultrasound, then is this billable service?

Answ er:

Charging for Point-of-Care (POC) ultrasound in the ERcan be complicated

The CPT® manual states that ALL ultrasound requires image documentation and a final, written report, which some hand-held portable POCUSdevices are not capable of providing:

?Use of ult rasound, w it hout t horough evaluat ion of organ(s) or anat om ic region, im age docum ent at ion, and final, w rit t en report , is not separat ely report able.?

If permanent images from the POCultrasound are obtained and stored, and a radiologist interprets the images and generates a written report, then this would be a billable service

For POCultrasound, if there is no written report generated and there is no interpretation by a radiologist, there is no technical fee since this does not meet the CPT® requirements for reporting ultrasound studies. There is also no professional fee since no professional services were rendered If the radiologist reads the images from the POCUSand generates a report, they will bill for the professional fee for the interpretation of the USimages. The American College of Emergency Physicians (ACEP) offers the following guidance for non-radiologist interpretations of ultrasound exams in the ED: https://www acep org/patient-care/policy-statements/interpretation-of-imaging-diagnostic-tests

?Interpretation of critical testing must be available 24 hours per day, 7 days per week Int erpret at ion should be com plet ed by a provider w ho m eet s or exceeds t he requirem ent s of t he inst it ut ion in w hich t he pat ient is receiving care.Off-site interpretation may be utilized, provided the process follows institutional and American College of Radiology (ACR) guidelines. It is preferred that off-site radiologists be credentialed by the hospital medical staff where the studies are performed Cont em poraneous int erpret at ion m ay be done by t heem ergency m edicine providers or by anot her specialist w it hin t he lim it s of t he t raining, experience, and com pet ence of t hat physician. Qualit y assurance of non-radiology int erpret at ions should follow inst it ut ional guidelines

Per U S Centers for Medicare & Medicaid Services (CMS) guidance, the provider performing contemporaneous interpretations of diagnostic studies is entitled to reimbursement for such interpretations. Interpretations should be available immediately to the ordering provider or their designee in accordance with institutional guidelines.

If the emergency physician believes that an urgent consultation with a radiologist is needed for the interpretation of a diagnostic study, that consultant must be immediately available for discussion and/or consultation with the treating physician.

?Whether the consultation is provided from a hospital staff physician or by an external contracted consultant, this physician should be board certified in radiology and licensed in the state where the images are obtained and should meet or exceed the credentialing requirements for physicians credentialed by the local health care facility

There are two additional issues of concern with charging for POCultrasound in the ER:

1)Most diagnostic ultrasound studies have very specific documentation requirements that must be met in order to bill for a complete ultrasound study CPT® code selection for the point-of-care ultrasound should be based on the specific documentation from the radiologist?s final, written report for the service. The radiology report serves as the documentation for both the professional and technical components of the procedure The below CorroHealth paper contains specific information about the documentation required for certain diagnostic USexams

Ultrasound Documentation Requirements: Complete vs. Limited

If the POCUSexam does not support the documentation/performance requirements for a complete ultrasound, it must be billed as a limited study This could become an issue if the patient goes on to have a second, more complete diagnostic ultrasound of the same anatomic site in the imaging department during an ED visit

Charging for both USstudies could potentially be appropriate if both are truly medically necessary, but the limited ultrasound would require a modifier in order to bypass NCCI edits for complete & limited studies billed on the same claim/same date of service (see example below). Charging for both ultrasounds would likely result in denials