ED Coding and Reimbursement Alert

It's a common emergency department scenario: The physician orders an ultrasound for a female patient with abdominal pain or vaginal bleeding. You apply routine obstetric or pelvic ultrasound codes, but they don't deliver payment.

Pregnancy ultrasound coding can bring on labor pains you didn't expect. Learn its subtle nuances to ease the struggle and ensure accurate codes. When treating females with pain and bleeding, emergency physicians must distinguish between intrauterine death (e.g., 656.4 series), spontaneous abortion (634 series), ectopic pregnancy (633 series) disorders of the ovary, fallopian tube, and broad ligament such as ruptured ovarian cyst or ovarian torsion (620 series), and other conditions.

Bedside ultrasound helps ED physicians quickly identify the presence of an intrauterine pregnancy, for example. An ultrasound also detects the presence of free fluid in the pelvic peritoneum a condition that determines critical clinical decision-making. Choosing the appropriate code to ensure reimbursement for this type of US depends on criteria that are tough to discern, warns Stephen Hoffenberg, MD, chairman-elect of the ultrasound sections of the American College of Emergency Physicians (ACEP) and president of CarePoint, a 150-physician emergency group in Denver.

Two criteria determine codes for ultrasounds evaluating abdominal pain and vaginal bleeding. You must determine both the patient's pregnancy status and the symptoms that necessitated the service, Hoffenberg says. The Most Common Pregnancy US Scenario If the physician knows about the pregnancy before he performs the ultrasound, and the US evaluates pregnancy-related conditions, then use an obstetric pelvic code for ultrasound, e.g., 76815 (Ultrasound, pregnant uterus, B-scan and/or real time with image documentation; limited [fetal size, heart beat, placental location, fetal position, or emergency in the delivery room]), Hoffenberg says.

Apply these obstetric ultrasound codes to pregnant patients who require ultrasounds for pregnancy-related conditions regardless of test results. The ultrasound could reveal an ectopic pregnancy, a spontaneous abortion or a molar pregnancy, but it could expose a nonpregnancy-related condition instead. Apply the obstetric codes from the 768xx series regardless, Hoffenberg says. These codes accurately capture services rendered to the "known to be pregnant" patient. Most of the time, emergency physicians know that the patient is pregnant, and the ultrasound evaluates a pregnancy-related condition, says Vivek Tayal, MD, an emergency physician at Carolina Medical Center in Charlotte, N.C., and contributor to the ACEP ultrasound reimbursement paper. "The most common code and more accurate code for most emergency physicians is the limited pelvic ultrasound where pregnancy is known, 76815," he states. But it's important to have solutions to other coding scenarios in your repertoire, Tayal adds. When the US Evaluates Nonpregnancy Conditions For example, an ultrasound was ordered to evaluate gallstones, a nonobstetric condition, in a pregnant patient. Because the exam evaluated a condition unrelated to [...]