 Prostate Ultrasound Reimbursement Packet
General Information
All ultrasound examinations must meet the requirements of medical necessity as set forth by the payer, must meet the requirements of completeness for the code that is chosen and must be documented in the patient's record, regardless of the type of ultrasound equipment that is used.
Documentation Requirements
All diagnostic ultrasound examinations, including those when ultrasound is used to guide a procedure, require permanently recorded images. The images can be kept in the patient 's record or some other archive - they do not need to be submitted with the claim. Images can be stored as printed images, on a tape or electronic medium. Documentation of the study must be available to the insurer upon request.
A written report of all ultrasound studies should be maintained in the patient's record. In the case of ultrasound guidance studies, the written report may be filed as a separate item in the patient's record or it may be included within the report of the procedure for which the guidance is utilized.
Third Party Insurance Payment Policies
Private insurance payment rules vary by payer and plan with respect to which specialties may perform and receive reimbursement for ultrasound services. Some payers will reimburse providers of any specialty for ultrasound services while others may restrict imaging procedures to specific specialties or providers only. Some private plans require physicians to submit applications requesting ultrasound be added to their list of services performed in their practice.
Contact your private payers before submitting claims to determine their requirements and request that they add ultrasound to your list of services.
Medicare will reimburse surgeons for medically necessary diagnostic ultrasound services, provided the services are within the scope of the physician's license. Some Medicare carriers require that the physician who performs and/or interprets some types of ultrasound examinations be capable of demonstrating relevant, documented training through recent residency training or post-graduate CME and experience. Contact your Medicare Part B Carrier for details.
Site of Service Payment Rules
In the office setting, a physician who owns the equipment and performs the service him or herself or through an employed or contracted sonographer, may bill the global fee, which is represented by the CPT code without any modifiers. In the hospital setting, physicians typically may not submit a "global" charge to payers, or otherwise bill third party payers for the technical component.
Physicians may bill Medicare for the global ultrasound service in the ambulatory surgery center (ASC) site of service so long as the imaging service is reasonable and medically necessary and directly related to the performance of a surgical procedure, i.e., the imaging must provide guidance of the procedure. Also, the physician must be the actual service provider exercising control and oversight.
- The physician and the ASC should enter into a contract that sets out terms for the physician to pay fair market value to the ASC for those elements of the technical component services that the ASC provides.
- Call your Medicare carrier to confirm that you can receive payment for the global service in that setting. This carve-out is relatively new, thus carrier policies and claims processing may not be updated.
- Private payer policies will differ - contact your payers directly for guidance on submitting claims for ultrasound services in this setting.
Use of Modifiers
If the site of service is the hospital, the -26 modifier, indicating that only the professional service was provided, must be added to the CPT code for the primary service. Payers will not reimburse physicians for the technical component in the hospital setting. If reporting a surgical procedure such as a biopsy on the same day as an office visit, add modifier -25 to the office visit code to indicate a "significant, separately identifiable evaluation and management service." However, this modifier is not to be used routinely. The E/M service must be "... above and beyond the usual preoperative and postoperative care associated with the procedure that was performed." (CPT Assistant, May 2003.) Be sure to document in the patient's record all components of the E&M service.
Code Selection
It is the physician's responsibility to select the codes that accurately describe the service performed and the corresponding reason for the study. Under the Medicare program, the physician should select the diagnosis or ICD-9 code based upon the test results, with two exceptions. If the test does not yield a diagnosis or was normal, the physician should use the pre-service signs, symptoms and conditions that prompted the study. If the test is a screening examination ordered in the absence of any signs or symptoms of illness or injury, the physician should select "screening" as the primary reason for the service and record the test results, if any, as additional diagnoses.
Payment Information
The following chart provides payment information for the ultrasound services discussed in this guide. Use the column entitled "Global Payment" to estimate reimbursement for services provided in the office and ASC setting. Use the "Professional Payment" column to estimate reimbursement to the physician for services provided in the facility setting. APC codes and payments are used by Medicare to reimburse facilities for technical component services under the Hospital Outpatient Prospective Payment System.
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