Ultrasound FAQ

Yes, per CPT 2024, “The performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The interpretation of the results of diagnostic tests/studies (i.e., professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended."

For each diagnostic ultrasound performed/coded (even if limited or focused), the following is necessary:

• Written Report/Interpretation - The patient's chart should include a report/interpretation for all diagnostic ultrasound studies. The minimum content of each interpretation should include the study being performed, the views obtained, the respective findings, and a separate final interpretation of the study. Ideally, the distinction between a complete or limited (focused) exam should be noted.
• Medical Necessity - The medical record should clearly state the medical justification for the test (indications for the study). Additionally, many payers use claim editors to compare CPT codes with the associated ICD-10 diagnosis codes to justify denying payment for services rendered. Correctly matching ICD-10 codes with diagnostic ultrasound CPT codes can increase the likelihood of receiving reimbursement for the interpretation without needing an appeals process.
• Image Retention - Diagnostic ultrasound images must be permanently stored and retrievable. This can be within the chart, a middleware program, or another archival system. The number of images, type (dynamic vs static), views, and storage medium may vary from facility to facility and have not been mandated by CPT or CMS. A minimum of one image demonstrating relevant anatomy/pathology (with measurements, if applicable) for each procedure coded should be retained and readily available. Please note that a stored image is mandatory to report CPT codes for all diagnostic and procedure guidance ultrasounds.  

For consideration for Medicare patients, in April 2011, the Office of Inspector General (OIG) reported on “Medicare Payments for Diagnostic Radiology Services in Emergency Departments”. In summary, providers play a vital role when completing the documentation to support claims for payment for Diagnostic Radiology Services. The key elements of the medical record documentation should include (1) physician/QHP’s orders to support diagnostic radiology services performed and (2) complete interpretation and reports. During the review, the OIG used the American College of Radiology’s (ACR) suggested documentation practice guidelines as a guidance document, which can be found on the ACR website. 

In summary, the ACR recommends that reports of radiology services include the following:

1. Demographics (facility name, patient name, exam date and time, etc.)  
2. Relevant clinical information   
3. Body of report (description of study, findings, limitations, etc.)   
4. Impression (diff dx, diagnosis, additional studies recommended, adverse reactions, etc.)   

The ACEP Ultrasound Section provides Emergency Ultrasound Standard Reporting Guidelines. These guidelines include documentation above and beyond what is required for coding. The core recommendations for documentation are to provide (1) patient demographics, (2) an indication for the exam, (3) views, (4) findings, (5) interpretation, and (6) quality assurance.

Additional Recommendations:

• The report should identify who performed and interpreted the procedure.   
• The scope of the study should be described, including whether the study was complete or limited, a repeat examination by the same physician/QHP, a repeat examination by a second physician/QHP, and/or a reduced level of service.   

A complete ultrasound exam attempts to visualize and diagnostically evaluate all major structures within the anatomic region. For example, a complete abdominal ultrasound (76700) would include real-time imaging of the liver, gallbladder, common bile duct, pancreas, spleen, kidneys, upper abdominal aorta, and inferior vena cava, including any demonstrated abdominal abnormality.

As defined by CPT, a limited ultrasound exam is one in which fewer than the required elements for a complete exam are performed and documented. Given the nature of the focused ED ultrasound examinations, the limited codes are typically the most accurate for utilization in the ED setting. For example, an abdominal ultrasound used to evaluate the presence of an abdominal aortic aneurysm would be reported as a “limited retroperitoneal ultrasound” (76775).

The one common exception to the rule is the transvaginal ultrasound in the pregnant (76817) and non-pregnant (76830) patient, for which there is no corresponding limited procedure CPT.  In these cases, a -52 modifier, which is a service reduction modifier, could be included to indicate that the ultrasound is not a complete study. Alternatively, the unlisted code 76999, unlisted ultrasound procedure (e.g., diagnostic, interventional) may be assigned with the appropriate comparison RVU along with submission of the record for payer review.

Ultrasound codes are combined, or “global,” service codes that include both the technical component (TC) and the professional component (notated by modifier -26). In the emergency department setting, the hospital will typically report the technical component that covers the cost of equipment, supplies, and personnel necessary for performing the service. The physician/QHP reports the professional component for the ultrasound interpretation and documentation of the results with the -26 Professional Component modifier. Modifier -26 is the most common modifier used with ultrasounds in the emergency department. When reporting diagnostic ultrasound interpretations by the ED physician, modifier -26 (Professional Component Only) should always be reported to signify that only the professional component is being billed.

Nothing in CPT prohibits practitioners from reporting the technical component (TC) if they provide all the necessary elements. However, some payers with which the practitioner participates might have policies prohibiting payment of the TC to practitioners. For example, Medicare will not pay the technical component to hospital-based (but non-hospital-employed) practitioners, even if they own the equipment, provide the supplies, and have their personnel perform the technical service.

Some emergency physician practices have contemplated purchasing their own ultrasound machines and billing for the global (professional plus technical) service. Given the compliance complexities of these business relationships, groups considering this option are well advised to seek legal counsel.

CPT Modifiers -76 and -77 indicate a repeat procedure, or service has been performed. These modifiers may be used with ultrasound CPT codes if a repeat ultrasound is necessary for patient care. Modifier -76 would be attached to the diagnostic ultrasound CPT code (in addition to modifier -26) if a repeat ultrasound and interpretation were performed on the same patient during the same encounter. Modifier -77 would indicate that a repeat ultrasound interpretation by a different physician/QHP has been performed.  Documenting the medical necessity for the repeat procedure in the patient’s medical record to support using these modifiers is essential.

Modifier -52 is a reduced services modifier. It may be included in cases in which no limited ultrasound CPT code exists, but the performed ultrasound is less than a complete study (e.g., transvaginal ultrasound in the pregnant (76817) and non-pregnant (76830) patient).

The code is based on the location of the abnormality. The following codes would be reported for the specific site.

It should be noted that CPT 2023 added new parenthetical instructions for CPT code 76882.

Code 76882 represents a limited evaluation of a joint or focal evaluation of a structure(s) in an extremity other than a joint (e.g., soft-tissue mass, fluid collection, or nerve[s]). Limited evaluation of a joint includes assessment of a specific anatomic structure(s) (e.g., joint space only [effusion] or tendon, muscle, and/or other soft-tissue structure[s] that surround the joint) that does not assess all of the required elements included in 76881. Code 76882 also requires permanently recorded images and a written report containing a description of each of the elements evaluated. CPT 2024 page 561.

There is no single CPT-defined code that describes a Focused Assessment with Sonography in Trauma (FAST) exam. Instead, the exam is reported with two CPT codes for a standard FAST exam or three CPT codes for an EFAST, depending on the extent of the ultrasound examinations performed and the level of detail included in the documented interpretation:

1. The cardiac component of the exam is reported with the CPT code for a limited transthoracic echocardiogram (93308).   
2. The abdominal component of the exam is reported with the CPT code for limited abdominal ultrasound (76705).   

The thoracic component (e.g., hemothorax or pneumothorax evaluation, if performed) of the exam is reported with the CPT code for limited chest ultrasound (76604).

Yes. The patient's pregnancy status and the purpose of the ultrasound examination determine the proper code.

Transabdominal ultrasound:

• When the patient is known to be pregnant, and the physician/QHP uses an ultrasound to evaluate the pregnancy or a suspected complication of or to the pregnancy, then the obstetric pelvic code should be used (76815).   
• When the patient is NOT pregnant, or the pregnancy status is unknown prior to the examination, and the ultrasound is used to evaluate pelvic pain, amenorrhea, vaginal bleeding or non-gynecologic pelvic pathology, then the non-obstetric code should be used (76857). 

Transvaginal ultrasound:

• There are two codes depending on the pregnancy status.   
  • If the patient is pregnant, use code (76817).   
  • If the patient is NOT pregnant, use code (76830).   
• It is important to note that there is only a complete exam code for a transvaginal ultrasound. Many emergency department transvaginal ultrasounds are limited exams; thus, using the modifier -52 Reduced Services in these cases is appropriate. Alternatively, the unlisted code 76999, unlisted ultrasound procedure (e.g., diagnostic, interventional) may be assigned with the appropriate comparison RVU along with submission of the record for payer review.
• Example: pregnant transvaginal ultrasound, professional service only (76817-26, -52 or 76999-26).

Code (76937) is explicitly used for vascular access with ultrasound guidance. The current CPT description is as follows:

"Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting." 

This is an add-on code, so it is added to the primary procedure code for billing.

There are several unique aspects of central venous and peripheral vascular access with ultrasound guidance code of which users must be aware. The first is that the code is intended for use only when the ultrasound is used with the "dynamic" technique, as opposed to the "static" technique, which is not considered a reimbursable service.

The static technique utilizes ultrasound to identify the vessel but is not used during line placement. In the dynamic technique, the physician/QHP uses the ultrasound throughout the procedure, from initial identification of the vessel through direct visualization of the needle entering the vessel. A permanently recorded image is required for to report the CPT code for ultrasound guidance. 

The CPT description is interpreted as requiring an image of the target vessel, but not necessarily an image of the needle in the vessel as it enters. Obtaining an image of the needle as it enters the vessel poses unacceptable risks to the patient, as it would require the physician/QHP to take their attention away from the procedure to obtain an image. It is recommended that permanent recording of the selected vessel or the needle in the vessel, when feasible and safe while using a procedure note to document the procedure, was performed with concurrent real-time visualization.  While a still image of the target vessel prior to successful cannulation is acceptable, a post-procedural still image of the catheter in the vessel, once the line is secure, is preferable.

Generally, it is appropriate to code for both the ultrasound guidance and the procedure performed. For example, when performing an I&D of an abscess with ultrasound assistance, both the I&D CPT code, e.g., 10060, and the ultrasound guidance for needle placement 76942 could be coded. Documentation requirements for coding ultrasound guidance differ from diagnostic ultrasound requirements (see page 16, CPT Assistant August 2021, for a clinical example of documentation requirements for ultrasound guidance procedures).

However, several codes have evolved to include ultrasound in the performance of the procedure (e.g., knee arthrocentesis with ultrasound guidance, 20611).

The following are ED-relevant procedures where imaging guidance is included, and the ultrasound cannot be reported separately.

• Thoracentesis (32555)
• Paracentesis (49083)
• Pericardiocentesis (33016)
• Arthrocentesis (20604, 20606, 20611)
• Introduction/Injection of Anesthetic Agent aka Nerve Block or Digital Block (added in 2023) (64415, 64416, 64417, 64445, 64446, 64447, 64448, 64451, 64454)

These procedures are frequently performed with imaging guidance, but the ultrasound is not included and can be reported separately.

• Incision and Drainage Subcutaneous (10060, 10061)
• Puncture Aspiration (10160)
• Incision and Foreign Body Removal (10120, 10121)
• Central Venous Catheter Insertion (36555, 36556)
• Drainage of Tonsil or Peritonsillar Abscess (42700)
• Aspiration of Bladder by Needle (51100)
• Diagnostic Lumbar Puncture (62270)

Introduction/Injection of Anesthetic Agent aka Nerve Block or Digital Block (64400, 64405, 64408, 64420, 64421, 64425, 64430, 64435, 64449, 64450).

It is generally allowable under CPT for two different physicians/QHPs (e.g., two different medical specialists) to report a limited and complete exam of the same anatomic description at different exam sessions on the same date of service if the medical record supports the medical necessity of the two separate procedures.

For example, on some occasions, an initial limited examination by an emergency physician/QHP will be inconclusive or demonstrate an unexpected finding requiring a complete examination by another medical specialist. It is required that each examination, limited or complete, stand on its merit as a medically necessary study. It is important to document in the medical record why a repeat or follow-up study was required.

It is not permissible, however, for the same physician/QHP to code for a limited exam followed by a complete exam of the same anatomic region in the same exam session. The limited exam is considered included or “bundled” into the more comprehensive complete service.

When coding for a limited and complete exam by two different practitioners, the -77 modifier "Repeat Procedure by another physician/QHP" by the second medical specialist might help justify payment for both studies.

However, it is important to note that some payers might recognize only the more complete examination and, therefore, pay for the complete study only, denying payment for the limited evaluation procedure done by the emergency physician/QHP.

It may be clinically necessary for the same physician/QHP to conduct multiple examinations if significant interval changes have occurred or are suspected. When coding the repeat exam, it is appropriate to use the -76 modifier "Repeat procedure by the same physician/QHP."

CPT, however, states in its general instructions that "…the ‘limited’ code for that anatomic region should be used once per patient exam session." Serial examinations over different exam sessions can be coded, but be sure that the medical record clearly demonstrates the medical necessity for each subsequent exam to address the expected payer denials.

CPT clearly identifies the requirements for complete and limited ultrasound services. CPT does not explicitly require an emergency physician/QHP to be credentialed by a hospital or a specialty society to provide these services.

Local medical bylaws may limit access to the equipment necessary to perform the services. State law and/or contractual agreements might otherwise limit a physician/QHP’s ability to provide or report the service.

For additional information regarding emergency department US services, see the Ultrasound section of Practice Resources on the ACEP website.

The Emergency Ultrasound Section has several essential documents that provide a more in-depth discussion of billing and coding topics:

Focused Cardiac Ultrasound in the Emergent Setting (PDF)

Standard Reporting Guidelines: Ultrasound for Procedure Guidance (PDF)

Emergency Ultrasound Standards Reporting Guidelines (PDF)