Wiki CPT Bedside Ultrasound Knee

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bellefried

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Patient comes into the ED for knee pain. Imaging was done through radiology. Additionally, the provider performed a bedside ultrasound. Documentation says ED POCUS (point of care ultrasound). “Linear ultrasound was placed to the anterior knee to evaluate for fluid collections. There is no large abscess or fluid collection.” “I did do a bedside ultrasound anterior to the knee and did not see any large collections.”

I have been searching for a CPT code to bill for the professional fee. 76882 seems to fit but I am not sure what the requirement of "with image documentation" means? Does this mean images are recorded, because there is no indication in the chart that images were documented. Otherwise 76999 for unlisted ultrasound procedure is the only other code I could find.
 
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Hello,

"With Image Documentation" means that the person who did the ultrasound took a "screenshot" of the area of interest from the ultrasound monitor, saved the image, and transferred the image to a radiology picture archiving system (PACS). If there is no "saved image" in the hospital PACS system, there is no proper documentation.

76882 Ultrasound, limited, joint or focal evaluation of other nonvascular extremity structure(s)

This is the correct code; which modifier (26/TC) or other is used, or does this US only count towards the MD's E/M charge? You would have to consult with the radiology department to find out this information and how your institution choose to deal with this particular situation.
 
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Thank you. It is bedside and performed by the ED provider, so I am trying to bill the profee charge, 76882-26. I don't need it to count towards the providers E/M charge. The doc didn't have pictures anywhere in the chart but did document findings. Would I still be able to bill 76882-26 if they only provided their findings but no images?
 
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To submit the code correctly, a picture of the area of interest must be included either on paper or in digital format in the chart or PACS. CMS requires visual documentation of the scan, and for this purpose, the MD should have taken a screenshot of the negative area and added it to the chart. What the MD did at the bedside is called a "quick look" and is not considered a complete study.

The patient should not be charged for the scan/study if no picture is available. Images are considered part of the medical record. If the patient wanted a second opinion of the study, there are no images for comparison; therefore, technically, the study/scan does not exist.

It is important to note that if CMS audits you without finding an image in the chart or PACS, it can create problems.
 
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