Billing, Coding And Documentation Prerequisites Of OB Ultrasound


In order to bill for ultrasounds, you have to ask yourself some questions first. For instance, what’s the stage of the pregnancy? What was the reason for the ultrasound? Where was it performed? How many fetuses were there?

Last but not the least, does the payer limit the number of ultrasounds? And this is real important that you know what your contract says because if it says two ultrasounds and unfortunately, she was infertile and the infertility specialist used up one of them before handing you over for care - and the payer says, “We don't care who does the ultrasounds. It's two then you've got one left.” So, you don't want to waste it. You want to use the one that they are going to pay for it in a way that's appropriate for the fetus and the mother, and gets you the most information.

Coding Rules For OB Ultrasound

There are some general coding rules that you will find in your CPT book regarding how to code for these. A modifier -25 is generally not required when billing an E/M service with an ultrasound. That's a CPT rule. More and more payers are requiring a -25 modifier if you are trying to bill and E/M and an ultrasound on the same day.

Now, this will occur more frequently when it's a radiology department that is performing the ultrasound and the patient is then brought into the room after the ultrasound to discuss the results with her, then the physician in the ultrasound department is the one billing the E/M service.

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Per ACOG and CPT, a modifier -51 is not added for multiple ultrasound codes. Unfortunately, there are payers out there that say, “No, we want to see the -51 modifier.” If they're going to reduce it, they're going to reduce it irrespective of a modifier being present. But you have to know that ACOG and CPT disagree. There should be no modifier for multiple ultrasounds.

If the person performing the ultrasound does not own the machine, you add a modifier -26 to the ultrasound code. Reason? Because the physician billing for the ultrasound is not providing the technical component of it. He is providing the professional component which involves the interpretation and a formal written report.

You can under CPT rule bill a transvaginal and an abdominal ultrasound procedure for the same session. However, almost every payer out there is looking for medical indication for those two approaches. If it turns out you're the practice that automatically does both and it's for the exact same reason for both of them and if you are not documenting separately both approaches, you can expect if the payer comes back and looks at your documentation, you will probably be giving some money back.

Documentation Rules

Under CPT rules, if you don't do everything described as having to be documented in the code, you have to pick a lesser code. Separate approaches need separate documentation. This goes without saying; it cannot be the absolute repeat. If you're doing transabdominal, the documentation has to show what you saw at that view. And when you go in to do the transvaginal scan, then the documentation should talk about exactly what was seen from that view. So, two separate approaches, two separate documentations can be in the same report.

Only the person who documents the interpretation gets to bill for it. If you have a situation where the hospital has an ultrasonographer who automatically reads this and you as the physician are also trying to read this and claiming that you did the professional component, the one who gets the claim in first is probably going to be the one who gets paid and the other one will not. Although, Medicare rules state that the physician who uses the information in the treatment of the patient is the one who should be paid in this situation. So, it doesn't mean you can't make a case with the payer.

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