AMA CPT® Assistant - 2009 Issue 5 (May)
Reporting Ultrasounds (May 2009)
May 2009 page 7 Coding Brief:Reporting Ultrasounds Question: Are there specific CPT codes that should be reported to describe the use of portable ultrasound devices at the patient's bedside? Answer: The assignment of the appropriate ultrasound code is based on the type of study performed, not the type of equipment used to perform the study or the indication for the study. Report the ultrasound code according to the anatomic area studied (eg, chest or abdomen). For anatomic regions with "complete" and "limited" ultrasound codes, note the elements that comprise a "complete" examination. The report should contain a description of...
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Article Overview
This CPT Assistant article reviews general ultrasound reporting principles and selected scenarios involving diagnostic ultrasound in different anatomic areas. It is useful for coders, billers, and radiology practices that need to understand how ultrasound study type, documentation, and reporting context affect code selection and modifier use. The article also points readers to related CPT and radiology coding resources.
Why This Topic Matters
Ultrasound reporting can vary based on anatomy, study scope, and service setting, so clear guidance helps reduce inconsistent billing and incomplete documentation. The article addresses common coding questions that arise in radiology and related outpatient or facility settings.
Article Sections
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Coding Brief: Reporting Ultrasounds
Introduces the topic and addresses general ultrasound reporting considerations, including study documentation and service setting.
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Bedside and facility-based ultrasound reporting
Covers how ultrasound services are reported when performed at the patient bedside or in a facility, along with documentation and modifier considerations.
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Diagnostic ultrasound of the pleural spaces
Addresses a chest ultrasound scenario involving evaluation of the pleural spaces and related anatomic coverage questions.
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Ultrasound of a palpable soft-tissue mass
Discusses code selection based on the location of a palpable subcutaneous abnormality across several anatomic regions.
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Multiple traumatic subcutaneous foreign bodies
Reviews reporting considerations when ultrasound is used to locate foreign bodies in more than one region and mentions related modifier use.
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Gallbladder diagnostic ultrasound
Addresses ultrasound reporting for a gallbladder-focused study and contrasts limited and complete abdominal ultrasound concepts.
What You Will Learn
- General principles for reporting ultrasound studies
- How anatomy and study scope affect ultrasound code selection
- Documentation elements expected for separately reportable ultrasound services
- How reporting context can affect modifier use
- How selected ultrasound scenarios are handled across different body regions
Who Should Read This
- Professional coders
- Radiology coders
- Billing staff
- Radiology practices
- Compliance staff
Codes Discussed
Modifiers Discussed
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