Wiki Bedside Ultrasound

[dmarshall]

Good morning,

Our OB/GYN dept had a patient that was being seen for her routine prenatal visit. She complained of headache for the last 2 days and during the visit her BP was elevated and they did a bedside ultrasound and also performed a BPP with the documented scoring system and medical reason of elevated BP. My question: is there a requirement of image retention to bill out the BPP when being performed with the use of the bedside ultrasound only? And would you provide the resources please as I will need to submit this to our Didactic Meeting. I thought I read in the ACR Radiology Coding Source that reporting of this score satisfies the required documentation of the study being performed, I want to make sure before I submit this information.

Bedside ultrasound preformed, Presentation: Cephalic, Placenta: Anterior, AFI: 23, MVP: 7 and EFW: 7 lbs 3 oz

Biophysical Profile (BPP):
Fetal movement: 2/2
Fetal tone: 2/2
Fetal breathing: 2/2
AFI: 23 cm
Score 8/8

Thank you so much!

 

[nielynco]

Good morning,

Our OB/GYN dept had a patient that was being seen for her routine prenatal visit. She complained of headache for the last 2 days and during the visit her BP was elevated and they did a bedside ultrasound and also performed a BPP with the documented scoring system and medical reason of elevated BP. My question: is there a requirement of image retention to bill out the BPP when being performed with the use of the bedside ultrasound only? And would you provide the resources please as I will need to submit this to our Didactic Meeting. I thought I read in the ACR Radiology Coding Source that reporting of this score satisfies the required documentation of the study being performed, I want to make sure before I submit this information.

Bedside ultrasound preformed, Presentation: Cephalic, Placenta: Anterior, AFI: 23, MVP: 7 and EFW: 7 lbs 3 oz

Biophysical Profile (BPP):
Fetal movement: 2/2
Fetal tone: 2/2
Fetal breathing: 2/2
AFI: 23 cm
Score 8/8

Thank you so much!

Per an ACR publication in 2007: A biophysical profile consists of five elements — four of which are studied with ultrasound, and the fifth element, which involves a nonstress test usually administered by the patient's obstetrician. The four elements that are scored from an ultrasound study are amniotic fluid, breathing, gross body movements, and fine motor movements. A score of "2" or "0"is given for each element, and the radiology report will give the score received out of the possible 8 points, in the format "8/8". Reporting of this score satisfies the required documentation of the study being performed.

This documentation does not, however, address the requirement as stated in CPT for permanently recorded images with measurements. If this bedside ultrasound did not provide this, you have not met the requirements for billing the procedure.

 

[dmarshall]

Per an ACR publication in 2007: A biophysical profile consists of five elements — four of which are studied with ultrasound, and the fifth element, which involves a nonstress test usually administered by the patient's obstetrician. The four elements that are scored from an ultrasound study are amniotic fluid, breathing, gross body movements, and fine motor movements. A score of "2" or "0"is given for each element, and the radiology report will give the score received out of the possible 8 points, in the format "8/8". Reporting of this score satisfies the required documentation of the study being performed.

This documentation does not, however, address the requirement as stated in CPT for permanently recorded images with measurements. If this bedside ultrasound did not provide this, you have not met the requirements for billing the procedure.

Thank you so very much Melanie, your guidance and knowledge is so appreciated.

Dorine Marshall,CPC,COBGC
Tulsa,Ok